Provider Demographics
NPI:1720608912
Name:EASTMAN, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
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 1:184 ELM ST APT 3
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-5515
Mailing Address - Country:US
Mailing Address - Phone:781-475-4736
Mailing Address - Fax:
Practice Address - Street 1:1337 HYDE PARK AVE
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:MA
Practice Address - Zip Code:02136-2713
Practice Address - Country:US
Practice Address - Phone:617-364-9880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-17
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
MAPA7499363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical