Basic Information
| Provider Information | |||||||||
| NPI: | 1225251416 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCEVOY | ||||||||
| FirstName: | COLLEEN | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22210 | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946232210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105354000 | ||||||||
| FaxNumber: | 5105354189 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 PIONEER LN | ||||||||
| Address2: | |||||||||
| City: | BISHOP | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935142556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608732849 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 05/01/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | NP16714 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | FHC70543G | 05 | CA | MEDICAID |