Basic Information
| Provider Information | |||||||||
| NPI: | 1982294237 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | RN/SRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 902 BROAD ST APT 6 | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238631872 | ||||||||
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| Practice Location | |||||||||
| Address1: | 130 W RAVINE RD | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232244000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2021 | ||||||||
| LastUpdateDate: | 10/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 220234 | TN | N | Nursing Service Providers | Registered Nurse | 367500000X | 30283 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.