Provider Demographics
NPI:1649156035
Name:PRUSISZ, EVAN
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:PRUSISZ
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 1:468 HAYSTACK DR
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19711
Mailing Address - Country:US
Mailing Address - Phone:302-518-0626
Mailing Address - Fax:
Practice Address - Street 1:16301 ELLIOTT PKWY, WILLIAMSPORT, MD 21795
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:MD
Practice Address - Zip Code:21795
Practice Address - Country:US
Practice Address - Phone:240-313-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-12
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer