Healthcare Provider Details

I. General information

NPI: 1902601768
Provider Name (Legal Business Name): EVAN MICHAEL LUNG RN, BSN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2025
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 RANDALLIA DR
FORT WAYNE IN
46805-4638
US

IV. Provider business mailing address

1408 BARON CT
AUBURN IN
46706-3250
US

V. Phone/Fax

Practice location:
  • Phone: 260-373-4000
  • Fax:
Mailing address:
  • Phone: 260-357-8048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number28303571A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: