Provider Demographics
NPI:1396911830
Name:N EVANS EINTERPRISES LLC
Entity type:Organization
Organization Name:N EVANS EINTERPRISES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-706-0113
Mailing Address - Street 1:417 NORTH MAIN
Mailing Address - Street 2:P.O. BOX 243
Mailing Address - City:GRANITE
Mailing Address - State:OK
Mailing Address - Zip Code:73547-0243
Mailing Address - Country:US
Mailing Address - Phone:580-535-4598
Mailing Address - Fax:580-535-4725
Practice Address - Street 1:417 N. MAIN
Practice Address - Street 2:
Practice Address - City:GRANITE
Practice Address - State:OK
Practice Address - Zip Code:73547
Practice Address - Country:US
Practice Address - Phone:580-535-4598
Practice Address - Fax:580-535-4725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK802363A00000X
OK261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOKB5170Medicare PIN