Healthcare Provider Details

I. General information

NPI: 1053392241
Provider Name (Legal Business Name): HENRY ALEXANDER EASLEY III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 03/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 S 17TH ST
WILMINGTON NC
28401-7407
US

IV. Provider business mailing address

2131 S 17TH ST
WILMINGTON NC
28401-7407
US

V. Phone/Fax

Practice location:
  • Phone: 910-772-9202
  • Fax: 910-772-9452
Mailing address:
  • Phone: 910-772-9202
  • Fax: 910-772-9452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number27368
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: