Provider Demographics
NPI:1245476597
Name:EVANS, MATTHEW SHANE (CPO)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:SHANE
Last Name:EVANS
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 COFFEE RD
Mailing Address - Street 2:SUITE1
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-2809
Mailing Address - Country:US
Mailing Address - Phone:209-544-2273
Mailing Address - Fax:209-544-2274
Practice Address - Street 1:1705 COFFEE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2809
Practice Address - Country:US
Practice Address - Phone:209-544-2273
Practice Address - Fax:209-544-2274
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-16
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPO02042224P00000X, 222Z00000X, 224L00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXC0020420Medicaid
CA6721560001Medicare NSC