Basic Information
Provider Information | |||||||||
NPI: | 1215315551 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | EVANS | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | CHENG | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CHENG | ||||||||
OtherFirstName: | JENNIFER | ||||||||
OtherMiddleName: | LINDA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2008 CARIBOU DR | ||||||||
Address2: |   | ||||||||
City: | FORT COLLINS | ||||||||
State: | CO | ||||||||
PostalCode: | 805254325 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9704844757 | ||||||||
FaxNumber: | 9704844759 | ||||||||
Practice Location | |||||||||
Address1: | 1024 S LEMAY AVE | ||||||||
Address2: |   | ||||||||
City: | FORT COLLINS | ||||||||
State: | CO | ||||||||
PostalCode: | 805243929 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9704957000 | ||||||||
FaxNumber: | 9377235016 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/06/2015 | ||||||||
LastUpdateDate: | 07/21/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/21/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 67080 | MN | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 390200000X | OH | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 2362 | NE | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 13482A | WY | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | DR.0065611 | CO | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.