Provider Demographics
NPI:1164099313
Name:EVANS, KARL BRUCE
Entity Type:Individual
Prefix:
First Name:KARL
Middle Name:BRUCE
Last Name:EVANS
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 1:771 S EAST AVE APT 777
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360-5958
Mailing Address - Country:US
Mailing Address - Phone:856-839-5423
Mailing Address - Fax:856-691-0708
Practice Address - Street 1:771 S EAST AVE APT 777771S
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-5958
Practice Address - Country:US
Practice Address - Phone:856-839-5423
Practice Address - Fax:856-691-0708
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ0450656388343800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343800000XTransportation ServicesSecured Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0450656388Medicaid