Provider Demographics
NPI:1487715405
Name:EASTMAN, NANCY M (PA-C)
Entity type:Individual
Prefix:MS
First Name:NANCY
Middle Name:M
Last Name:EASTMAN
Suffix:
Gender:F
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 1:820 4TH ST N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-4539
Mailing Address - Country:US
Mailing Address - Phone:701-234-6161
Mailing Address - Fax:701-234-6161
Practice Address - Street 1:4622 40TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-4394
Practice Address - Country:US
Practice Address - Phone:701-364-2909
Practice Address - Fax:701-364-9346
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2011-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9637363A00000X
NDPAC0342363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S80726Medicare UPIN