Provider Demographics
NPI:1265139331
Name:FROST, EVAN JACKSON (EMT-B)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:JACKSON
Last Name:FROST
Suffix:
Gender:M
Credentials:EMT-B
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 BISHOPS LODGE RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1131
Mailing Address - Country:US
Mailing Address - Phone:505-819-7317
Mailing Address - Fax:
Practice Address - Street 1:2052 GALISTEO ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-2100
Practice Address - Country:US
Practice Address - Phone:505-819-3419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-09
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1016380146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic