Provider Demographics
NPI:1720095896
Name:EVANS, TIMOTHY J
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
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 1:3377 JOE WHEELER BROWN RD
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MS
Mailing Address - Zip Code:38843-7245
Mailing Address - Country:US
Mailing Address - Phone:662-790-4902
Mailing Address - Fax:
Practice Address - Street 1:1301 S ADAMS ST
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MS
Practice Address - Zip Code:38843
Practice Address - Country:US
Practice Address - Phone:662-862-4422
Practice Address - Fax:662-862-4244
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR819687363L00000X, 363LF0000X
LAAP09666363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAAP09666OtherBOARD OF NURSING