Provider Demographics
NPI:1750526463
Name:EVORS, LAURA JANE
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:JANE
Last Name:EVORS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 POPLAR RD STE 120
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-8301
Mailing Address - Country:US
Mailing Address - Phone:770-400-4510
Mailing Address - Fax:678-423-2737
Practice Address - Street 1:775 POPLAR RD STE 120
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-8301
Practice Address - Country:US
Practice Address - Phone:770-400-4510
Practice Address - Fax:678-423-2737
Is Sole Proprietor?:No
Enumeration Date:2008-12-09
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC39393207V00000X
GA82210207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC393933Medicaid
SCSC89176162OtherMEDICARE PIN