Provider Demographics
NPI:1912981853
Name:EVANS, BENJAMIN MARVIN (RN APN-C)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:MARVIN
Last Name:EVANS
Suffix:
Gender:M
Credentials:RN APN-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 EGE AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07304-1413
Mailing Address - Country:US
Mailing Address - Phone:201-333-1094
Mailing Address - Fax:201-333-6226
Practice Address - Street 1:155 JEFFERSON ST
Practice Address - Street 2:MENTAL HEALTH-4W
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-1706
Practice Address - Country:US
Practice Address - Phone:973-465-2605
Practice Address - Fax:973-465-2829
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NC07677700163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6741100Medicaid