Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | D4484 | TX |
N | 207QH0002X | Family Doctor - Hospice and Palliative Medicine | D4484 | TX |
NPI | 1275561540 |
---|---|
Provider Name | Edmond C Evans JR. |
First Address | Mineral Wells, TX 76067-8246 |
Second Address | Mineral Wells, TX 76067-8246 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/06/2006 |
Last Update Date | 28/04/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
033822002 | (05) | TX |
8U9490 | BCBS (01) | TX |
D83795 | (02) | TX |