Healthcare Provider Details

I. General information

NPI: 1326767195
Provider Name (Legal Business Name): ELIZABETH ANNE EASTMAN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BETH EASTMAN PTA

II. Dates (important events)

Enumeration Date: 08/25/2022
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 CENTENNIAL CENTRE BLVD
HOBART WI
54155-8989
US

IV. Provider business mailing address

595 PEBBLESTONE CIR
HOBART WI
54155-9386
US

V. Phone/Fax

Practice location:
  • Phone: 920-544-5041
  • Fax:
Mailing address:
  • Phone: 252-571-5696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number3302-19
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: