Provider Demographics
NPI:1699216986
Name:EASTMAN, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:EASTMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6938A THURSBY AVE
Mailing Address - Street 2:
Mailing Address - City:ARVERNE
Mailing Address - State:NY
Mailing Address - Zip Code:11692-1138
Mailing Address - Country:US
Mailing Address - Phone:347-234-1830
Mailing Address - Fax:718-213-4606
Practice Address - Street 1:6938A THURSBY AVE
Practice Address - Street 2:
Practice Address - City:ARVERNE
Practice Address - State:NY
Practice Address - Zip Code:11692-1138
Practice Address - Country:US
Practice Address - Phone:347-234-1830
Practice Address - Fax:718-213-4606
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-20
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY431855-1163WI0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY$$$$$$$$$-AMedicaid