Provider Demographics
NPI:1780670141
Name:EVANS, DIANA MURCIA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:MURCIA
Last Name:EVANS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:DIANA
Other - Middle Name:
Other - Last Name:MURCIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:9500 BORMET DR
Mailing Address - Street 2:STE 204
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-8399
Mailing Address - Country:US
Mailing Address - Phone:708-346-4044
Mailing Address - Fax:708-346-3287
Practice Address - Street 1:4400 W 95TH ST STE 308
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2660
Practice Address - Country:US
Practice Address - Phone:708-346-4040
Practice Address - Fax:708-346-3287
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085000517363AS0400X
IN10000333A363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN970022880Medicare PIN
ILR78367Medicare UPIN
IL970003769Medicare PIN
IL970022881Medicare PIN