Provider Demographics
NPI:1730138942
Name:EVANS, SHANE M (OD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:M
Last Name:EVANS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 E P TRUE PARKWAY
Mailing Address - Street 2:STE 103
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50265
Mailing Address - Country:US
Mailing Address - Phone:515-225-0877
Mailing Address - Fax:515-225-9518
Practice Address - Street 1:1905 E P TRUE PARKWAY
Practice Address - Street 2:STE 103
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50265
Practice Address - Country:US
Practice Address - Phone:515-225-0877
Practice Address - Fax:515-225-9518
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01940152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA3065482Medicaid
IA2065482Medicaid
IA0065482Medicaid
410029175Medicare PIN
410029173Medicare PIN
410029174Medicare PIN
09209Medicare PIN
U00940Medicare UPIN
IA3065482Medicaid
I8289Medicare PIN
IA0065482Medicaid
07227Medicare PIN