Provider Demographics
NPI:1679009468
Name:EVANS, RANDALL MONTEAL JR
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:MONTEAL
Last Name:EVANS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 BRUCE AVE
Mailing Address - Street 2:
Mailing Address - City:FERGUSON
Mailing Address - State:MO
Mailing Address - Zip Code:63135-2704
Mailing Address - Country:US
Mailing Address - Phone:314-372-5011
Mailing Address - Fax:
Practice Address - Street 1:226 BRUCE AVE
Practice Address - Street 2:
Practice Address - City:FERGUSON
Practice Address - State:MO
Practice Address - Zip Code:63135-2704
Practice Address - Country:US
Practice Address - Phone:314-372-5011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
No374T00000XNursing Service Related ProvidersReligious Nonmedical Nursing Personnel