Provider Demographics
NPI:1487226437
Name:EID, EVAN
Entity Type:Individual
Prefix:MR
First Name:EVAN
Middle Name:
Last Name:EID
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 1:130 S KNOWLES AVE
Mailing Address - Street 2:
Mailing Address - City:NEW RICHMOND
Mailing Address - State:WI
Mailing Address - Zip Code:54017-1727
Mailing Address - Country:US
Mailing Address - Phone:715-246-3018
Mailing Address - Fax:
Practice Address - Street 1:1100 BERGSLIEN ST
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:WI
Practice Address - Zip Code:54002-2600
Practice Address - Country:US
Practice Address - Phone:715-684-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-10
Last Update Date:2021-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11486-33367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered