Healthcare Provider Details

I. General information

NPI: 1841182318
Provider Name (Legal Business Name): EVAN KELLER GUM STUDENT IN PROGRAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2025
Last Update Date: 07/17/2025
Certification Date: 07/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1959 NE PACIFIC ST
SEATTLE WA
98195-0001
US

IV. Provider business mailing address

1735 DEXTER AVE N APT A505
SEATTLE WA
98109-6221
US

V. Phone/Fax

Practice location:
  • Phone: 206-543-8736
  • Fax:
Mailing address:
  • Phone: 925-209-5406
  • 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: