Provider Demographics
NPI:1659453439
Name:EVANS, LORI JO (PA-C)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:JO
Last Name:EVANS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:J
Other - Last Name:O'BRIEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2005 MIZELL AVE STE 2100
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-4126
Mailing Address - Country:US
Mailing Address - Phone:407-599-6460
Mailing Address - Fax:407-599-6461
Practice Address - Street 1:2005 MIZELL AVE STE 2100
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-4126
Practice Address - Country:US
Practice Address - Phone:407-599-6460
Practice Address - Fax:407-599-6461
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-002502363A00000X
FLPA9106376363A00000X
FLPA 9106376363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH11907432OtherCAQH
OH0156040Medicaid
OH0156040Medicaid