Provider Demographics
NPI:1902832033
Name:EACKER, ALLENSCOTT W (PA)
Entity Type:Individual
Prefix:
First Name:ALLENSCOTT
Middle Name:W
Last Name:EACKER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4550 EXECUTIVE DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34119-8805
Mailing Address - Country:US
Mailing Address - Phone:716-830-6224
Mailing Address - Fax:239-566-2519
Practice Address - Street 1:4550 EXECUTIVE DR
Practice Address - Street 2:SUITE 104
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34119-8805
Practice Address - Country:US
Practice Address - Phone:716-830-6224
Practice Address - Fax:239-566-2519
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0033391207P00000X
FLPA9104665363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY970018313OtherRAILROAD MEDICARE
NY161480107OtherFIDELIS
NY161480107OtherINDEPENDENT HEALTH
NY00011220501OtherUNIVERA
NY000570552002OtherBLUE CROSS BLUE SHIELD
NY000570552002OtherBLUE CROSS BLUE SHIELD
NYBB4575Medicare ID - Type Unspecified