Provider Demographics
NPI:1831577592
Name:EVANSON, WYLIE
Entity type:Individual
Prefix:
First Name:WYLIE
Middle Name:
Last Name:EVANSON
Suffix:
Gender:M
Credentials:
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 21044
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89515-1044
Mailing Address - Country:US
Mailing Address - Phone:775-830-7774
Mailing Address - Fax:
Practice Address - Street 1:1001 PYRAMID WAY STE 202
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89431-4470
Practice Address - Country:US
Practice Address - Phone:775-742-1235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-14
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program