Provider Demographics
NPI:1851871172
Name:EVANS, RUSSELL L (PA-C)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:L
Last Name:EVANS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:320 WARNER DR
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4441
Mailing Address - Country:US
Mailing Address - Phone:208-743-3523
Mailing Address - Fax:208-208-8741
Practice Address - Street 1:320 WARNER DR
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4441
Practice Address - Country:US
Practice Address - Phone:208-743-3523
Practice Address - Fax:208-746-8741
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ID18518711722085R0204X
MN4084472471C3401X, 2471C3402X
WAPA61007077363A00000X
IDPA-1823363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2471C3401XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistComputed Tomography
No2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1851871172Medicaid
ID1851871172Medicaid