Healthcare Provider Details

I. General information

NPI: 1790317626
Provider Name (Legal Business Name): MR. EVAN EDWARD FASSBENDER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2020
Last Update Date: 08/14/2020
Certification Date: 08/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6019 WALNUT GROVE RD
MEMPHIS TN
38120-2113
US

IV. Provider business mailing address

519 S EDGEWOOD ST APT 201
MEMPHIS TN
38104-4365
US

V. Phone/Fax

Practice location:
  • Phone: 901-226-5000
  • Fax:
Mailing address:
  • Phone: 251-408-1824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number194971
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number27968
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: