Provider Demographics
NPI:1205887114
Name:O'NEILL, EVONN LB (MD)
Entity type:Individual
Prefix:DR
First Name:EVONN
Middle Name:LB
Last Name:O'NEILL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5952 BLACKSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:NINE MILE FALLS
Mailing Address - State:WA
Mailing Address - Zip Code:99026-4900
Mailing Address - Country:US
Mailing Address - Phone:509-464-3627
Mailing Address - Fax:509-466-9517
Practice Address - Street 1:5952 BLACKSTONE WAY
Practice Address - Street 2:
Practice Address - City:NINE MILE FALLS
Practice Address - State:WA
Practice Address - Zip Code:99026-4900
Practice Address - Country:US
Practice Address - Phone:509-464-3627
Practice Address - Fax:509-466-9517
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036446207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8250649Medicaid
WA8906391OtherCRIME VICTIM COMPENSATION
WA0198643OtherWORKERS COMPENSATION
WA0198643OtherWORKERS COMPENSATION
H10063Medicare UPIN