Provider Demographics
NPI:1679519268
Name:EVANS, ELLIS E (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ELLIS
Middle Name:E
Last Name:EVANS
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 1:2550 N HOLLYWOOD WAY
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-1055
Mailing Address - Country:US
Mailing Address - Phone:818-557-0135
Mailing Address - Fax:818-557-1394
Practice Address - Street 1:869 NORTH CHERRY STREET
Practice Address - Street 2:
Practice Address - City:TULARE
Practice Address - State:CA
Practice Address - Zip Code:93274-2287
Practice Address - Country:US
Practice Address - Phone:559-685-3450
Practice Address - Fax:559-685-3869
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14524363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA14524Medicaid
CAPA14524Medicaid
CA0PA145241Medicare Oscar/Certification