Provider Demographics
NPI:1295434165
Name:EASTMAN, EAGLEBEAR
Entity type:Individual
Prefix:
First Name:EAGLEBEAR
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 1:314 REDBUD LN
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-5132
Mailing Address - Country:US
Mailing Address - Phone:539-234-3785
Mailing Address - Fax:
Practice Address - Street 1:214 N BLISS AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-2520
Practice Address - Country:US
Practice Address - Phone:539-234-3785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-28
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist