Provider Demographics
NPI:1528002441
Name:EVANS, TANYA B (MD)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:B
Last Name:EVANS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18700 N 64TH DR STE 301
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-7114
Mailing Address - Country:US
Mailing Address - Phone:602-883-3700
Mailing Address - Fax:602-883-3703
Practice Address - Street 1:18700 N 64TH DR STE 301
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7114
Practice Address - Country:US
Practice Address - Phone:602-883-3700
Practice Address - Fax:602-883-3703
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25590207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ401216Medicaid
AZ107567Medicare ID - Type Unspecified
AZ401216Medicaid