Provider Demographics
NPI:1760796395
Name:EASTHAM, DOUGLAS A (PA-C)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:A
Last Name:EASTHAM
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 1:3000 EDWARD CURD LN
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-5791
Mailing Address - Country:US
Mailing Address - Phone:615-791-2630
Mailing Address - Fax:615-791-2639
Practice Address - Street 1:3000 EDWARD CURD LN
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37067-5791
Practice Address - Country:US
Practice Address - Phone:615-791-2630
Practice Address - Fax:615-791-2639
Is Sole Proprietor?:No
Enumeration Date:2010-08-06
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4038225100000X, 363AS0400X, 363AM0700X
IL085003810363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085003810Medicaid
IL1181750001Medicare NSC