Healthcare Provider Details

I. General information

NPI: 1073254975
Provider Name (Legal Business Name): EVAN STRAUB
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 04/05/2022
Certification Date: 04/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1364 CLIFTON RD NE STE H-100
ATLANTA GA
30322-1059
US

IV. Provider business mailing address

402 PEMBROKE AVE APT 1
NORFOLK VA
23507-2244
US

V. Phone/Fax

Practice location:
  • Phone: 404-727-0093
  • Fax: 404-712-0561
Mailing address:
  • Phone: 410-302-2696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: