Provider Demographics
NPI:1104871284
Name:EVANS, MICHAEL J (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:EVANS
Suffix:
Gender:M
Credentials:PA
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Other - Last Name:
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Mailing Address - Street 1:255 LAFAYETTE AVE
Mailing Address - Street 2:GOOD SAMARITAN HOSPITAL
Mailing Address - City:SUFFERN
Mailing Address - State:NY
Mailing Address - Zip Code:10901-4812
Mailing Address - Country:US
Mailing Address - Phone:845-368-8800
Mailing Address - Fax:845-368-5608
Practice Address - Street 1:255 LAFAYETTE AVE
Practice Address - Street 2:GOOD SAMARITAN HOSPITAL
Practice Address - City:SUFFERN
Practice Address - State:NY
Practice Address - Zip Code:10901-4812
Practice Address - Country:US
Practice Address - Phone:845-368-8800
Practice Address - Fax:845-368-5608
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY000533-1363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S73005Medicare UPIN
023880B8AMedicare ID - Type Unspecified