Basic Information
| Provider Information | |||||||||
| NPI: | 1770507857 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | LEWIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6002 | ||||||||
| Address2: | |||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618036002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173833311 | ||||||||
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| Practice Location | |||||||||
| Address1: | 311 WEST FAIRCHILD STREET | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174317650 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 08/28/2008 | ||||||||
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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 | 363AM0700X | A419 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 085003219 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | S200419 | 01 | SC | SOUTH CAROLINA DEA # | OTHER | 0533210001 | 01 | DMERC | OTHER | ME0241567 | 01 | FEDERAL DEA # | OTHER |