Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207XS0117X | Orthopaedic Spine Surgeon | 4301051829 | MI |
NPI | 1194713669 |
---|---|
Provider Name | Kenneth J Easton |
First Address | Grand Rapids, MI 49525 |
Second Address | Grand Rapids, MI 49525 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/10/2005 |
Last Update Date | 04/02/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
4763007 | (05) | TX |
F52967 | (02) | |
P00240358 | RR MEDICARE (01) |