Provider Demographics
NPI:1699821793
Name:EVORA, GISELLE DIZON (NP)
Entity Type:Individual
Prefix:MRS
First Name:GISELLE
Middle Name:DIZON
Last Name:EVORA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 629
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSTED
Mailing Address - State:VI
Mailing Address - Zip Code:00821-0629
Mailing Address - Country:US
Mailing Address - Phone:340-778-5780
Mailing Address - Fax:
Practice Address - Street 1:4500 SION FARM
Practice Address - Street 2:ISLAND MEDICAL CENTER, SUITE 3B
Practice Address - City:CHRISTIANSTED
Practice Address - State:VI
Practice Address - Zip Code:00820
Practice Address - Country:US
Practice Address - Phone:340-778-5780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303582363LA2200X
VI10977P363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02975015Medicaid
NY02975015Medicaid