Healthcare Provider Details

I. General information

NPI: 1659205045
Provider Name (Legal Business Name): EASTON HALVERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 JEFFERSON ST
WEST UNION IA
52175-1022
US

IV. Provider business mailing address

112 JEFFERSON ST
WEST UNION IA
52175-1022
US

V. Phone/Fax

Practice location:
  • Phone: 563-422-3817
  • Fax:
Mailing address:
  • Phone: 563-422-3811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number139466
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: