Provider Demographics
NPI:1023521424
Name:BROOKBANK, EVAN MILES
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:MILES
Last Name:BROOKBANK
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 1:175 S 36TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-3682
Mailing Address - Country:US
Mailing Address - Phone:740-644-8152
Mailing Address - Fax:
Practice Address - Street 1:175 S 36TH ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-3682
Practice Address - Country:US
Practice Address - Phone:740-644-8152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-08
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer