Basic Information
| Provider Information | |||||||||
| NPI: | 1356794432 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EISAMAN | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | EISAMAN | ||||||||
| OtherFirstName: | JACKSON | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1400 E KINCAID ST | ||||||||
| Address2: | ATTN: CREDENTIALING | ||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982744127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604282500 | ||||||||
| FaxNumber: | 3604286485 | ||||||||
| Practice Location | |||||||||
| Address1: | 9631 269TH ST NW | ||||||||
| Address2: | |||||||||
| City: | STANWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982928071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606291600 | ||||||||
| FaxNumber: | 3606291644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2016 | ||||||||
| LastUpdateDate: | 03/30/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA60686334 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | PA60686334 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.