Provider Demographics
NPI:1811942964
Name:EVANS, WILLIAM BRENT (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:BRENT
Last Name:EVANS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1244 NO MAIN ST, STE201
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:TN
Mailing Address - Zip Code:84074
Mailing Address - Country:US
Mailing Address - Phone:435-882-3968
Mailing Address - Fax:435-882-3859
Practice Address - Street 1:1244 NO MAIN ST, STE201
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:TN
Practice Address - Zip Code:84074
Practice Address - Country:US
Practice Address - Phone:435-882-3968
Practice Address - Fax:435-882-3859
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT274737-1205146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT52898551002Medicaid
UT52898551002Medicaid