Provider Demographics
NPI:1467747568
Name:EVANS, NATHANIEL R (MD)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:R
Last Name:EVANS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7221 HAGUE RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-1925
Mailing Address - Country:US
Mailing Address - Phone:812-240-4763
Mailing Address - Fax:
Practice Address - Street 1:210 VILLAGE CENTER BLVD STE 200
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-6706
Practice Address - Country:US
Practice Address - Phone:843-236-3222
Practice Address - Fax:843-236-3005
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-16
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC39886207X00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC39886OtherSOUTH CAROLINA LICENSE