Provider Demographics
NPI:1902825243
Name:EVANS, JASON CHARLES (PA-C)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:CHARLES
Last Name:EVANS
Suffix:
Gender:M
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 1:1095 W HURON ST
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-3735
Mailing Address - Country:US
Mailing Address - Phone:248-682-9611
Mailing Address - Fax:248-682-6051
Practice Address - Street 1:1095 W HURON ST
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-3735
Practice Address - Country:US
Practice Address - Phone:248-682-9611
Practice Address - Fax:248-682-6051
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003819363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP11560Medicare ID - Type Unspecified