Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | OS012305 | PA |
N | 207QS0010X | Family Doctor - Sports Medicine | OS012305 | PA |
NPI | 1083641260 |
---|---|
Provider Name | Dr. Stephen Evans |
First Address | Philadelphia, PA 19178-3311 |
Second Address | Pottsville, PA 17901-3660 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/06/2006 |
Last Update Date | 06/08/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
101872172 | (05) | PA |
H79578 | (02) |