Basic Information
| Provider Information | |||||||||
| NPI: | 1427269893 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EASTWOOD | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | WILSON | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8001 YOUREE DR STE 550 | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711152332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182123681 | ||||||||
| FaxNumber: | 3182123687 | ||||||||
| Practice Location | |||||||||
| Address1: | 8001 YOUREE DR STE 550 | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711152332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182123681 | ||||||||
| FaxNumber: | 3182123687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2007 | ||||||||
| LastUpdateDate: | 06/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA08539 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1133361 | 05 | LA | MEDICAID |