Provider Demographics
NPI:1467523530
Name:EVENSON, LISA RACHELLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:RACHELLE
Last Name:EVENSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:LISA
Other - Middle Name:RACHELLE
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1175 S PERRY ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-1969
Mailing Address - Country:US
Mailing Address - Phone:303-688-3434
Mailing Address - Fax:303-688-4454
Practice Address - Street 1:1175 S PERRY ST
Practice Address - Street 2:SUITE 200
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-1969
Practice Address - Country:US
Practice Address - Phone:303-688-3434
Practice Address - Fax:303-688-4454
Is Sole Proprietor?:No
Enumeration Date:2006-11-12
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2242363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO807667Medicare PIN