Provider Demographics
NPI:1689849945
Name:EVANS, AKE S (MD)
Entity Type:Individual
Prefix:
First Name:AKE
Middle Name:S
Last Name:EVANS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 N MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:LOVINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:88260-2830
Mailing Address - Country:US
Mailing Address - Phone:575-396-6611
Mailing Address - Fax:575-396-1454
Practice Address - Street 1:1600 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:LOVINGTON
Practice Address - State:NM
Practice Address - Zip Code:88260-2830
Practice Address - Country:US
Practice Address - Phone:575-396-6611
Practice Address - Fax:575-396-1454
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA103068208100000X
NMMD2015-0595208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
9651706OtherAETNA PROVIDER NUMBER
CAA103068OtherMEDICAL BOARD LICENSE
NM88730336Medicaid
CA12205977OtherCAQH PROVIDER NUMBER
CAA103068OtherMEDICAL BOARD LICENSE
CAFC666ZMedicare PIN
CA12205977OtherCAQH PROVIDER NUMBER
CAFC666XMedicare PIN