Individual
EVAN PAUL PROVISOR
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
94 SOUTH ST, SOUTHBRIDGE, MA 01550-4000
(508) 764-6966
(508) 764-2457
Mailing address
94 SOUTH ST, SOUTHBRIDGE, MA 01550-4000
(508) 764-6966
(508) 764-2457
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
237945
MA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2160307
—
MA
Enumeration date
12/13/2005
Last updated
12/21/2011
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