Provider Demographics
NPI:1669584033
Name:EVANS, SUSAN (NP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 W BULLARD AVE
Mailing Address - Street 2:SUITE 124
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-0861
Mailing Address - Country:US
Mailing Address - Phone:559-297-1300
Mailing Address - Fax:
Practice Address - Street 1:255 W BULLARD AVE
Practice Address - Street 2:SUITE 124
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-0861
Practice Address - Country:US
Practice Address - Phone:559-297-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7286363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA456373Medicaid