Provider Demographics
NPI:1477148823
Name:EASLER & WHITE MEDIVERSAL GROUP
Entity Type:Organization
Organization Name:EASLER & WHITE MEDIVERSAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JACKQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:EASLER
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:270-903-3168
Mailing Address - Street 1:922 TRIPLETT ST STE 7
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-3118
Mailing Address - Country:US
Mailing Address - Phone:270-903-3168
Mailing Address - Fax:
Practice Address - Street 1:922 TRIPLETT ST STE 7
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-3118
Practice Address - Country:US
Practice Address - Phone:270-903-3168
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100521780Medicaid