Basic Information
Provider Information | |||||||||
NPI: | 1285694059 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MIDDLETON | ||||||||
FirstName: | EILEEN | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3549 SOUTHERN HILLS DR | ||||||||
Address2: | SUITE 501 | ||||||||
City: | SIOUX CITY | ||||||||
State: | IA | ||||||||
PostalCode: | 511064736 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7122746729 | ||||||||
FaxNumber: | 7122746744 | ||||||||
Practice Location | |||||||||
Address1: | 600 4TH ST | ||||||||
Address2: | SUITE 501 | ||||||||
City: | SIOUX CITY | ||||||||
State: | IA | ||||||||
PostalCode: | 511011750 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7122340220 | ||||||||
FaxNumber: | 7122340225 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/24/2006 | ||||||||
LastUpdateDate: | 04/20/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 001320 | IA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 37256 | 01 | IA | WELLMARK | OTHER |