Provider Demographics
NPI:1457197048
Name:TREMBACK, EVAN
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:TREMBACK
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 1:904 HUDSON ST
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:18433-2039
Mailing Address - Country:US
Mailing Address - Phone:570-903-1349
Mailing Address - Fax:
Practice Address - Street 1:1800 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-2369
Practice Address - Country:US
Practice Address - Phone:570-703-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA006896363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant