Provider Demographics
NPI:1356794432
Name:EISAMAN, JACK (PA-C)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:EISAMAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:JACKSON
Other - Middle Name:
Other - Last Name:EISAMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1400 E KINCAID ST
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-428-2500
Mailing Address - Fax:360-428-6485
Practice Address - Street 1:9631 269TH ST NW
Practice Address - Street 2:
Practice Address - City:STANWOOD
Practice Address - State:WA
Practice Address - Zip Code:98292-8071
Practice Address - Country:US
Practice Address - Phone:360-629-1600
Practice Address - Fax:360-629-1644
Is Sole Proprietor?:No
Enumeration Date:2016-07-13
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60686334363A00000X, 363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical