Provider Demographics
NPI:1871639104
Name:JASON EVANS, PA
Entity Type:Organization
Organization Name:JASON EVANS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:954-776-0200
Mailing Address - Street 1:4750 N FEDERAL HWY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4609
Mailing Address - Country:US
Mailing Address - Phone:954-776-0200
Mailing Address - Fax:954-776-8475
Practice Address - Street 1:4750 N FEDERAL HWY
Practice Address - Street 2:SUITE 202
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4609
Practice Address - Country:US
Practice Address - Phone:954-776-0200
Practice Address - Fax:954-776-8475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 2835213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAA746OtherMEDICARE GROUP NUMBER
FLAA746OtherMEDICARE GROUP NUMBER