Provider Demographics
NPI:1316284151
Name:EASTLACK, JOAN (PA)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:EASTLACK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 PANAMA AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90814-1909
Mailing Address - Country:US
Mailing Address - Phone:562-961-3831
Mailing Address - Fax:
Practice Address - Street 1:432 PANAMA AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90814-1909
Practice Address - Country:US
Practice Address - Phone:562-961-3831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14906363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical