Provider Demographics
NPI:1205928983
Name:EVANS, MARK A (PA-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:EVANS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 476
Mailing Address - Street 2:
Mailing Address - City:GRANITE
Mailing Address - State:OK
Mailing Address - Zip Code:73547
Mailing Address - Country:US
Mailing Address - Phone:580-872-4362
Mailing Address - Fax:877-785-6691
Practice Address - Street 1:417 N MAIN
Practice Address - Street 2:
Practice Address - City:GRAINTE
Practice Address - State:OK
Practice Address - Zip Code:73547
Practice Address - Country:US
Practice Address - Phone:580-872-4362
Practice Address - Fax:877-785-6691
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK802363A00000X
OKOK802208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100054690AMedicaid
OK100699750CMedicaid
OKS32243Medicare UPIN