Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207P00000X | Emergency Physician | 03561R | LA |
NPI | 1013013960 |
---|---|
Provider Name | Dr. Thomas Charles Evans JR. |
First Address | Mccomb, MS 39648-7570 |
Second Address | Mccomb, MS 39648-7570 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/09/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1148041 | (05) | LA |
B63108 | (02) | LA |