1073873741 NPI number — COURTNEY A EASTMAN PA-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073873741 NPI number — COURTNEY A EASTMAN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EASTMAN
Provider First Name:
COURTNEY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073873741
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/09/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
135 CARMEN LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA MARIA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93458-7729
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-928-7361
Provider Business Mailing Address Fax Number:
805-928-5742

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1630 E HERNDON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRESNO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93720-3391
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-256-5200
Provider Business Practice Location Address Fax Number:
559-256-5376
Provider Enumeration Date:
05/29/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  22221 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 22221 . This is a "PHYSICAN ASSISTANT COMMITTEE LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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