Provider Demographics
NPI:1689187635
Name:EVANS, SHANNON NICOLE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICOLE
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:254 EASTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901-1766
Mailing Address - Country:US
Mailing Address - Phone:732-745-8600
Mailing Address - Fax:
Practice Address - Street 1:59 VERONICA AVE STE 201
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-3579
Practice Address - Country:US
Practice Address - Phone:732-828-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-13
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical