Provider Demographics
NPI:1528371325
Name:EVANS, ELIZABETH MARGARET
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARGARET
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 W GLENHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85045-1635
Mailing Address - Country:US
Mailing Address - Phone:480-232-0380
Mailing Address - Fax:480-460-0241
Practice Address - Street 1:1818 W GLENHAVEN DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85045-1635
Practice Address - Country:US
Practice Address - Phone:480-232-0380
Practice Address - Fax:480-460-0241
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-21
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2382I332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier