Provider Demographics
NPI:1679696611
Name:EVANS, ELLEN R (MD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:R
Last Name:EVANS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9662 N 29TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68112-1524
Mailing Address - Country:US
Mailing Address - Phone:402-510-9923
Mailing Address - Fax:
Practice Address - Street 1:9662 N 29TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68112-1524
Practice Address - Country:US
Practice Address - Phone:402-510-9923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE17202207Q00000X, 207QG0300X
TXG5030207Q00000X, 207QG0300X
OK14875207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine