Provider Demographics
NPI:1821632886
Name:EASTER, MARIO JAQUAN
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:JAQUAN
Last Name:EASTER
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 1:5644 BOYDTON PLANK RD
Mailing Address - Street 2:
Mailing Address - City:BRODNAX
Mailing Address - State:VA
Mailing Address - Zip Code:23920-2156
Mailing Address - Country:US
Mailing Address - Phone:434-532-5673
Mailing Address - Fax:
Practice Address - Street 1:5644 BOYDTON PLANK RD
Practice Address - Street 2:
Practice Address - City:BRODNAX
Practice Address - State:VA
Practice Address - Zip Code:23920-2156
Practice Address - Country:US
Practice Address - Phone:434-532-5673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-03
Last Update Date:2019-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)