Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 3212 | AZ |
N | 207QA0401X | Family Doctor - Addiction Medicine | 3212 | AZ |
N | 207RA0401X | Internist - Addiction Medicine | 3212 | AZ |
N | 207RI0200X | Infectious Disease | 3212 | AZ |
NPI | 1396789830 |
---|---|
Provider Name | Dr. S Foster Easley III |
First Address | Phoenix, AZ 85021 |
Second Address | Phoenix, AZ 85021 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/06/2006 |
Last Update Date | 08/01/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
579170 | (05) | AZ |