Provider Demographics
NPI:1619069804
Name:EVANCHO, WAYNE NICHOLAS (DO)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:NICHOLAS
Last Name:EVANCHO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1380 NE MIAMI GARDENS DRIVE
Mailing Address - Street 2:SUITE 285
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33179
Mailing Address - Country:US
Mailing Address - Phone:305-944-8777
Mailing Address - Fax:305-944-3006
Practice Address - Street 1:1380 NE MIAMI GARDENS DRIVE
Practice Address - Street 2:SUITE 285
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33179
Practice Address - Country:US
Practice Address - Phone:305-944-8777
Practice Address - Fax:305-944-3006
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS5535207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL06365500Medicaid
FL296403OtherAV MED
FL1214206OtherCIGNA
E70641Medicare UPIN
FL80166AMedicare ID - Type Unspecified