Provider Demographics
NPI:1881465649
Name:EVANS, EDWARD TYSON I
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:TYSON
Last Name:EVANS
Suffix:I
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 1:37931 STATE ROUTE 143
Mailing Address - Street 2:
Mailing Address - City:POMEROY
Mailing Address - State:OH
Mailing Address - Zip Code:45769-9697
Mailing Address - Country:US
Mailing Address - Phone:740-525-2672
Mailing Address - Fax:
Practice Address - Street 1:37931 STATE ROUTE 143
Practice Address - Street 2:
Practice Address - City:POMEROY
Practice Address - State:OH
Practice Address - Zip Code:45769-9697
Practice Address - Country:US
Practice Address - Phone:740-525-2672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty