Provider Demographics
NPI:1801574231
Name:HALL, EVAN JACOB
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:JACOB
Last Name:HALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 BLACK GRANITE RD NW
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52405-4796
Mailing Address - Country:US
Mailing Address - Phone:319-693-6883
Mailing Address - Fax:
Practice Address - Street 1:1300 BLACK GRANITE RD NW
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52405-4796
Practice Address - Country:US
Practice Address - Phone:319-693-6883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program