Provider Demographics
NPI:1568949477
Name:XANTHOS, EVAN (PA-C)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:XANTHOS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 N CHESTERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04938-6221
Mailing Address - Country:US
Mailing Address - Phone:207-491-9812
Mailing Address - Fax:
Practice Address - Street 1:1600 DELTA WATERS RD STE 107
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-9114
Practice Address - Country:US
Practice Address - Phone:541-858-2514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA189549363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant