Provider Demographics
NPI:1447770581
Name:EVANGELISTA, EDGAR SUNGLAO (NP)
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:SUNGLAO
Last Name:EVANGELISTA
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 S SHELLMAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3238
Mailing Address - Country:US
Mailing Address - Phone:323-363-3842
Mailing Address - Fax:
Practice Address - Street 1:250 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-4218
Practice Address - Country:US
Practice Address - Phone:626-857-3299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95006462363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily