Provider Demographics
NPI:1457571325
Name:EVANS, MARK W (DPM)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:EVANS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 EMBASSY DR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603-2387
Mailing Address - Country:US
Mailing Address - Phone:717-735-7410
Mailing Address - Fax:717-735-7438
Practice Address - Street 1:2101 EMBASSY DR
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17603-2387
Practice Address - Country:US
Practice Address - Phone:717-735-7410
Practice Address - Fax:717-735-7438
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC-003096L213ES0131X
PASC003096L213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1182516Medicaid
PA480006659OtherPALMETTO
PA02645500OtherCAPITAL BLUE CROSS
PA02645500OtherCAPITAL BLUE CROSS
PA192233Medicare PIN