Provider Demographics
NPI:1346056975
Name:EAGLE, ELAN JOSIAH
Entity type:Individual
Prefix:
First Name:ELAN
Middle Name:JOSIAH
Last Name:EAGLE
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 1:470819 E 810 RD
Mailing Address - Street 2:
Mailing Address - City:STILWELL
Mailing Address - State:OK
Mailing Address - Zip Code:74960-4240
Mailing Address - Country:US
Mailing Address - Phone:918-696-2285
Mailing Address - Fax:918-696-6746
Practice Address - Street 1:470819 E 810 RD
Practice Address - Street 2:
Practice Address - City:STILWELL
Practice Address - State:OK
Practice Address - Zip Code:74960-4240
Practice Address - Country:US
Practice Address - Phone:918-696-2285
Practice Address - Fax:918-696-6746
Is Sole Proprietor?:No
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant