Basic Information
| Provider Information | |||||||||
| NPI: | 1790317626 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FASSBENDER | ||||||||
| FirstName: | EVAN | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 519 S EDGEWOOD ST APT 201 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381044365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514081824 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6019 WALNUT GROVE RD | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381202113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012265000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2020 | ||||||||
| LastUpdateDate: | 08/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC0200X | 194971 | TN | N | Nursing Service Providers | Registered Nurse | Critical Care Medicine | 367500000X | 27968 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.