Provider Demographics
NPI:1598741068
Name:EASTMAN, MICHAEL J (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:EASTMAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3340 EAST GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:702-386-0909
Mailing Address - Fax:702-386-0707
Practice Address - Street 1:1055 NORTH CURTIS ROAD
Practice Address - Street 2:SOUTH TOWER, 6TH FLOOR
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1309
Practice Address - Country:US
Practice Address - Phone:208-367-4343
Practice Address - Fax:208-367-7667
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NV514207L00000X
363A00000X
IDPA-801363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002042036Medicaid
NV70063Medicare ID - Type Unspecified
NV002042036Medicaid
V38114Medicare Oscar/Certification