Healthcare Provider Details

I. General information

NPI: 1689556235
Provider Name (Legal Business Name): EVAN JURGENSEN
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 N 17TH ST
MILWAUKEE WI
53233-2104
US

IV. Provider business mailing address

507 N 17TH ST
MILWAUKEE WI
53233-2104
US

V. Phone/Fax

Practice location:
  • Phone: 763-350-3745
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: