Provider Demographics
NPI:1700586245
Name:EVANS, ROGER
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:EVANS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24118 N LAKE COCHRAN RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-8753
Mailing Address - Country:US
Mailing Address - Phone:206-606-3573
Mailing Address - Fax:
Practice Address - Street 1:909 W MAIN ST STE 102
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-2031
Practice Address - Country:US
Practice Address - Phone:360-453-7715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist