Provider Demographics
NPI:1295495299
Name:LITTLEBOY, ESTON (PA-C)
Entity type:Individual
Prefix:
First Name:ESTON
Middle Name:
Last Name:LITTLEBOY
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 1:1331 GUSDORF RD
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6282
Mailing Address - Country:US
Mailing Address - Phone:575-758-3601
Mailing Address - Fax:
Practice Address - Street 1:1331 GUSDORF RD
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6282
Practice Address - Country:US
Practice Address - Phone:575-758-3601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-19
Last Update Date:2021-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2021-0121208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice