Provider Demographics
NPI:1922011550
Name:EVANS, TRENTON J
Entity Type:Individual
Prefix:MR
First Name:TRENTON
Middle Name:J
Last Name:EVANS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:TRENT
Other - Middle Name:J
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:111 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6127
Mailing Address - Country:US
Mailing Address - Phone:208-336-0895
Mailing Address - Fax:208-338-1796
Practice Address - Street 1:111 W STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6127
Practice Address - Country:US
Practice Address - Phone:208-336-0895
Practice Address - Fax:208-338-1796
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX53373367500000X
IDRNA-517367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806208500Medicaid
ID806208500Medicaid