Provider Demographics
NPI:1134690852
Name:EVAN, JEREMIAH M
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:M
Last Name:EVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JEREMY
Other - Middle Name:M
Other - Last Name:EVAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:373 E 700 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-4046
Mailing Address - Country:US
Mailing Address - Phone:541-908-6335
Mailing Address - Fax:
Practice Address - Street 1:373 E 700 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-4046
Practice Address - Country:US
Practice Address - Phone:541-908-6335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program