Provider Demographics
NPI:1497287734
Name:GUILLIAMS, EVIN LAKE (DO)
Entity type:Individual
Prefix:
First Name:EVIN
Middle Name:LAKE
Last Name:GUILLIAMS
Suffix:
Gender:M
Credentials:DO
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 746647
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6647
Mailing Address - Country:US
Mailing Address - Phone:904-388-6518
Mailing Address - Fax:904-384-1005
Practice Address - Street 1:617 23RD ST STE 106
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2880
Practice Address - Country:US
Practice Address - Phone:606-329-1770
Practice Address - Fax:606-329-1768
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-28
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS21210207T00000X
KYTP273207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery