Healthcare Provider Details

I. General information

NPI: 1174596746
Provider Name (Legal Business Name): PHYLLIS EASON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 4TH ST S
FARGO ND
58103-1929
US

IV. Provider business mailing address

PO BOX 2168
FARGO ND
58107-2168
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-3100
  • Fax: 701-234-3120
Mailing address:
  • Phone: 701-234-2119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number043926
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number71925
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2015042689
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD61499166
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberC170232
License Number StateCA
# 6
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberPT12912
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: