Provider Demographics
NPI:1700887338
Name:EVANS, KELLY L (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:EVANS
Suffix:
Gender:F
Credentials:MD
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 5096
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98227-5096
Mailing Address - Country:US
Mailing Address - Phone:360-738-2200
Mailing Address - Fax:360-752-5686
Practice Address - Street 1:4545 CORDATA PKWY
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-7123
Practice Address - Country:US
Practice Address - Phone:360-738-2200
Practice Address - Fax:360-752-5686
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36096988207Q00000X
WAMD60114770207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1700887338Medicaid
IL036096988Medicaid
WA0031EVOtherREGENCE
WA0261814OtherL&I AND CRIME VICTIMS
WA5827708OtherAETNA
IL036096988Medicaid
WA5827708OtherAETNA
WAG8891584Medicare PIN