Basic Information
| Provider Information | |||||||||
| NPI: | 1376064634 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOULKE | ||||||||
| FirstName: | EVAN | ||||||||
| MiddleName: | EUGENE | ||||||||
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| Credential: | STUDENT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1924 ALCOA HWY # U-11 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379201511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8653059230 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1924 ALCOA HWY # U-11 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8653059230 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2017 | ||||||||
| LastUpdateDate: | 03/23/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 390200000X | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.