Provider Demographics
NPI:1477109718
Name:EASTEP, CARL DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:DAVID
Last Name:EASTEP
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1912 E LATANA DR
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-8274
Mailing Address - Country:US
Mailing Address - Phone:870-577-4991
Mailing Address - Fax:
Practice Address - Street 1:1901 E 32ND ST STE 4
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3071
Practice Address - Country:US
Practice Address - Phone:417-781-0250
Practice Address - Fax:417-781-2581
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-13
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019026919363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant