Basic Information
| Provider Information | |||||||||
| NPI: | 1083643654 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 108 S FRONTAGE RD W STE 300 | ||||||||
| Address2: | |||||||||
| City: | VAIL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 816575087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704761100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 108 S FRONTAGE RD W STE 300 | ||||||||
| Address2: | |||||||||
| City: | VAIL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 816575087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704761100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 01/08/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 42833 | CO | N | Allopathic & Osteopathic Physicians | Anesthesiology | 208VP0014X | 42833 | CO | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 73031577 | 05 | CO | MEDICAID | 023856 | 01 | CO | KAISER COMMERCIAL NUMBER | OTHER |