Provider Demographics
NPI:1891790580
Name:EVANS, LISA M (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:EVANS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:SHARON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3002
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632
Mailing Address - Country:US
Mailing Address - Phone:360-414-2385
Mailing Address - Fax:360-414-2386
Practice Address - Street 1:1615 DELAWARE ST.
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-0302
Practice Address - Country:US
Practice Address - Phone:360-414-2385
Practice Address - Fax:360-414-2386
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00044037207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0201114OtherLABOR & IND.
WA8435851Medicaid
WA8913895OtherCRIME VICTIMS
P00293336OtherRR MEDICARE
OR270056Medicaid
I42656Medicare UPIN
WA8435851Medicaid