Provider Demographics
NPI:1497748115
Name:EADES, MYRNA SUE
Entity Type:Individual
Prefix:MRS
First Name:MYRNA
Middle Name:SUE
Last Name:EADES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 E BENDER BLVD
Mailing Address - Street 2:
Mailing Address - City:HOBBS
Mailing Address - State:NM
Mailing Address - Zip Code:88240-2419
Mailing Address - Country:US
Mailing Address - Phone:505-392-1063
Mailing Address - Fax:505-392-7750
Practice Address - Street 1:1200 E BENDER BLVD
Practice Address - Street 2:
Practice Address - City:HOBBS
Practice Address - State:NM
Practice Address - Zip Code:88240-2419
Practice Address - Country:US
Practice Address - Phone:505-392-1063
Practice Address - Fax:505-392-7750
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNONE REQUIRED174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM4332610001Medicare NSC