Provider Demographics
NPI:1023518347
Name:WADSWORTH, EVAN R (PA)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:R
Last Name:WADSWORTH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:1199 HADLEY RD
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46158-1788
Practice Address - Country:US
Practice Address - Phone:317-831-2273
Practice Address - Fax:317-831-9347
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-13
Last Update Date:2023-09-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN10002428A363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300012898Medicaid