Provider Demographics
NPI:1962520395
Name:PATTISHALL, EVAN G III (MD)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:G
Last Name:PATTISHALL
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 STUDENT HEALTH CENTER
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PARK
Mailing Address - State:PA
Mailing Address - Zip Code:16802
Mailing Address - Country:US
Mailing Address - Phone:814-863-8542
Mailing Address - Fax:814-863-8464
Practice Address - Street 1:310 STUDENT HEALTH CENTER
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PARK
Practice Address - State:PA
Practice Address - Zip Code:16802
Practice Address - Country:US
Practice Address - Phone:814-863-8542
Practice Address - Fax:814-863-8464
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-030227-E208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPA448820OtherBLUE SHIELD
PAPA448820OtherBLUE SHIELD