Provider Demographics
NPI:1891708541
Name:EVANS, ELLIS WAYNE (MD)
Entity Type:Individual
Prefix:MR
First Name:ELLIS
Middle Name:WAYNE
Last Name:EVANS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 PINE STREET
Mailing Address - Street 2:SUITE 220
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201
Mailing Address - Country:US
Mailing Address - Phone:478-746-1396
Mailing Address - Fax:478-746-1997
Practice Address - Street 1:770 PINE STREET
Practice Address - Street 2:SUITE 220
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201
Practice Address - Country:US
Practice Address - Phone:478-746-1396
Practice Address - Fax:478-746-1997
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA013745208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
D39820Medicare UPIN