Provider Demographics
NPI:1871510735
Name:EVANSON, CANDYCE K (PA-C)
Entity Type:Individual
Prefix:
First Name:CANDYCE
Middle Name:K
Last Name:EVANSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:737 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58122-0001
Mailing Address - Country:US
Mailing Address - Phone:701-234-3360
Mailing Address - Fax:701-234-3868
Practice Address - Street 1:737 BROADWAY
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58122
Practice Address - Country:US
Practice Address - Phone:701-234-3360
Practice Address - Fax:701-234-3868
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9215363A00000X, 363AM0700X
NDPAC0168363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S16484Medicare UPIN