Provider Demographics
NPI:1508449380
Name:EVANS, MATTHEW JAMES
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAMES
Last Name:EVANS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 N VAN BUREN ST
Mailing Address - Street 2:
Mailing Address - City:CHERRY VALLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61016-9492
Mailing Address - Country:US
Mailing Address - Phone:815-298-3370
Mailing Address - Fax:
Practice Address - Street 1:2086 7TH ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-6192
Practice Address - Country:US
Practice Address - Phone:217-581-2712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program