Provider Demographics
NPI:1508815481
Name:EVANS, GAIL ANN (OD)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:ANN
Last Name:EVANS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-5532
Mailing Address - Country:US
Mailing Address - Phone:570-283-2120
Mailing Address - Fax:570-714-9790
Practice Address - Street 1:390 PIERCE STREET
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704
Practice Address - Country:US
Practice Address - Phone:570-283-2120
Practice Address - Fax:570-714-9790
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000807152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA056425RTBMedicare PIN
I27668Medicare UPIN