Provider Demographics
NPI:1265962385
Name:DAVIES, EVAN T (PHD, PA-C)
Entity type:Individual
Prefix:DR
First Name:EVAN
Middle Name:T
Last Name:DAVIES
Suffix:
Gender:M
Credentials:PHD, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7740 GUNSTON PLZ
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-1897
Mailing Address - Country:US
Mailing Address - Phone:703-878-0924
Mailing Address - Fax:
Practice Address - Street 1:2296 OPITZ BLVD STE 230
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3345
Practice Address - Country:US
Practice Address - Phone:703-878-0924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110005759363AS0400X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty