Provider Demographics
NPI:1346892585
Name:EASTERLY, PHILLIP WILLIAM (PT)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:WILLIAM
Last Name:EASTERLY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3915 W 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-1672
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9100 E 46TH ST N
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74115-1000
Practice Address - Country:US
Practice Address - Phone:580-541-6093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-09
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5729225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1346892585OtherNPI