Provider Demographics
NPI:1437312352
Name:EVANS, MARIAH (PA-C)
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARIAH
Other - Middle Name:
Other - Last Name:LEFFORGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:111 N NAPPANEE ST
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-1957
Mailing Address - Country:US
Mailing Address - Phone:574-522-0265
Mailing Address - Fax:
Practice Address - Street 1:111 N NAPPANEE ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1957
Practice Address - Country:US
Practice Address - Phone:574-522-0265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000990A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical