Provider Demographics
NPI:1770535254
Name:EVANGELISTA, NICK R (PA)
Entity type:Individual
Prefix:
First Name:NICK
Middle Name:R
Last Name:EVANGELISTA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:210 E DERENNE AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-6736
Mailing Address - Country:US
Mailing Address - Phone:912-644-5300
Mailing Address - Fax:912-644-5260
Practice Address - Street 1:210 E DERENNE AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-6736
Practice Address - Country:US
Practice Address - Phone:912-644-5300
Practice Address - Fax:912-644-5260
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2009-12-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA004375363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAS72808Medicare UPIN