Provider Demographics
NPI:1245794874
Name:GERVAIS, EVAN THOMAS (RN)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:THOMAS
Last Name:GERVAIS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:464 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-4260
Mailing Address - Country:US
Mailing Address - Phone:978-995-2866
Mailing Address - Fax:
Practice Address - Street 1:464 RIVER RD
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-4260
Practice Address - Country:US
Practice Address - Phone:978-995-2866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2309588163WE0003X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WE0003XNursing Service ProvidersRegistered NurseEmergency