Provider Demographics
NPI:1306617337
Name:EASDALE, DAN
Entity type:Individual
Prefix:
First Name:DAN
Middle Name:
Last Name:EASDALE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2311 NW VAN BUREN AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-5393
Mailing Address - Country:US
Mailing Address - Phone:541-224-1170
Mailing Address - Fax:
Practice Address - Street 1:2311 NW VAN BUREN AVE APT 5
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-5393
Practice Address - Country:US
Practice Address - Phone:541-224-1170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000107037172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker