Provider Demographics
NPI:1801535851
Name:EDELIST, EVAN
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:EDELIST
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:PO BOX 150429
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94915-0429
Mailing Address - Country:US
Mailing Address - Phone:415-300-5463
Mailing Address - Fax:
Practice Address - Street 1:114 SAN RAFAEL AVE
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3645
Practice Address - Country:US
Practice Address - Phone:415-300-5463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-28
Last Update Date:2022-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator