Provider Demographics
NPI:1124867403
Name:BLACK, EASTON ALAN (CAA)
Entity type:Individual
Prefix:
First Name:EASTON
Middle Name:ALAN
Last Name:BLACK
Suffix:
Gender:M
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58328 RICHPORT DR
Mailing Address - Street 2:
Mailing Address - City:SENECAVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43780-9456
Mailing Address - Country:US
Mailing Address - Phone:740-586-1115
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-868-8776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-24
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant