Provider Demographics
NPI:1790317626
Name:FASSBENDER, EVAN EDWARD
Entity Type:Individual
Prefix:MR
First Name:EVAN
Middle Name:EDWARD
Last Name:FASSBENDER
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 1:519 S EDGEWOOD ST APT 201
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-4365
Mailing Address - Country:US
Mailing Address - Phone:251-408-1824
Mailing Address - Fax:
Practice Address - Street 1:6019 WALNUT GROVE RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2113
Practice Address - Country:US
Practice Address - Phone:901-226-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-08
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN194971163WC0200X
TN27968367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine