Provider Demographics
NPI:1659021699
Name:PEREZ, EVAN (PA-C)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:PEREZ
Suffix:
Gender:F
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 1:19 BROWN ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-5744
Mailing Address - Country:US
Mailing Address - Phone:361-813-7539
Mailing Address - Fax:
Practice Address - Street 1:625 CLARK AVE # B
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-4068
Practice Address - Country:US
Practice Address - Phone:860-583-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-24
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5469363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant