Basic Information
| Provider Information | |||||||||
| NPI: | 1760796395 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EASTHAM | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 317 SEVEN SPRINGS WAY | ||||||||
| Address2: | STE 101 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370274576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153709992 | ||||||||
| FaxNumber: | 6153709665 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 S KOKE MILL RD | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627119252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175479100 | ||||||||
| FaxNumber: | 2175479236 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2010 | ||||||||
| LastUpdateDate: | 01/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 4038 | TN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 363AM0700X | 085003810 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | 4038 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AM0700X | 4038 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | 085003810 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 085003810 | 05 | IL | MEDICAID |