Provider Demographics
NPI:1558765891
Name:IVIE, EVAN DAYNE (PA)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:DAYNE
Last Name:IVIE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3456 E 17TH ST STE 190
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-6749
Mailing Address - Country:US
Mailing Address - Phone:208-524-2222
Mailing Address - Fax:855-999-9242
Practice Address - Street 1:14502 W MEEKER BLVD
Practice Address - Street 2:
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-5282
Practice Address - Country:US
Practice Address - Phone:623-524-4607
Practice Address - Fax:623-524-4182
Is Sole Proprietor?:No
Enumeration Date:2014-10-15
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5905363AM0700X
IDPA-1265363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1174919534Medicaid
ID473675862Medicaid