Healthcare Provider Details

I. General information

NPI: 1497016968
Provider Name (Legal Business Name): EASTON BESHEARS P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2012
Last Update Date: 09/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 JOHNSON FERRY RD SUITE 820
ATLANTA GA
30342-1626
US

IV. Provider business mailing address

550 PEACHTREE ST NE SUITE 1600
ATLANTA GA
30308-2208
US

V. Phone/Fax

Practice location:
  • Phone: 404-252-9307
  • Fax:
Mailing address:
  • Phone: 404-881-1094
  • Fax: 404-874-1249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.004358
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number007725
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: