Provider Demographics
NPI:1902182348
Name:EVANS, DAVID MICHAEL (PAC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MICHAEL
Last Name:EVANS
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2410 SUSANNAH ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1748
Mailing Address - Country:US
Mailing Address - Phone:423-282-9011
Mailing Address - Fax:423-722-0291
Practice Address - Street 1:2410 SUSANNAH ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1748
Practice Address - Country:US
Practice Address - Phone:423-282-9011
Practice Address - Fax:423-722-0291
Is Sole Proprietor?:No
Enumeration Date:2011-10-31
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2069363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical