Healthcare Provider Details

I. General information

NPI: 1902719180
Provider Name (Legal Business Name): EVERGREEN MEDICAL TRANSPORT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

881 NORMAN DR
STOUGHTON WI
53589-3055
US

IV. Provider business mailing address

881 NORMAN DR
STOUGHTON WI
53589-3055
US

V. Phone/Fax

Practice location:
  • Phone: 952-457-5408
  • Fax:
Mailing address:
  • Phone: 952-457-5408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL

VIII. Authorized Official

Name: HASSAN SHARIF
Title or Position: OWNER/MANAGER
Credential:
Phone: 952-457-5408