Provider Demographics
NPI:1780605188
Name:EVANS, SANDRA J (CRNA APN)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:J
Last Name:EVANS
Suffix:
Gender:F
Credentials:CRNA APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 TIMBERLINE TRL
Mailing Address - Street 2:
Mailing Address - City:ALTO PASS
Mailing Address - State:IL
Mailing Address - Zip Code:62905-2024
Mailing Address - Country:US
Mailing Address - Phone:618-893-2275
Mailing Address - Fax:618-893-2275
Practice Address - Street 1:117 TIMBERLINE TRL
Practice Address - Street 2:
Practice Address - City:ALTO PASS
Practice Address - State:IL
Practice Address - Zip Code:62905-2024
Practice Address - Country:US
Practice Address - Phone:618-893-2275
Practice Address - Fax:618-893-2275
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered