Provider Demographics
NPI:1851397459
Name:EASLEY, EVAN WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:WAYNE
Last Name:EASLEY
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 1:1520 VIRGINIA RANCH RD
Mailing Address - Street 2:
Mailing Address - City:GARDNERVILLE
Mailing Address - State:NV
Mailing Address - Zip Code:89410-5731
Mailing Address - Country:US
Mailing Address - Phone:775-782-1550
Mailing Address - Fax:775-782-1513
Practice Address - Street 1:1520 VIRGINIA RANCH RD
Practice Address - Street 2:
Practice Address - City:GARDNERVILLE
Practice Address - State:NV
Practice Address - Zip Code:89410-5731
Practice Address - Country:US
Practice Address - Phone:775-782-1550
Practice Address - Fax:775-782-1513
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7446207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002003024Medicaid
NV002003024Medicaid
F78167Medicare UPIN
NVV105672Medicare PIN