Provider Demographics
NPI:1386851087
Name:EATON, LAWRENCE D (PA)
Entity Type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:D
Last Name:EATON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2171 TRILLIUM DRIVE
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701
Mailing Address - Country:US
Mailing Address - Phone:715-831-9365
Mailing Address - Fax:
Practice Address - Street 1:2820 E PARK AVE
Practice Address - Street 2:NORTHERN WISCONSIN CTR FOR DO
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-0340
Practice Address - Country:US
Practice Address - Phone:715-723-5542
Practice Address - Fax:715-723-7957
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI283023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42940300Medicaid
WI42940300Medicaid