Provider Demographics
NPI:1427269893
Name:EASTWOOD, ROBERT WILSON (PA)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:WILSON
Last Name:EASTWOOD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1811 E BERT KOUNS INDUSTRIAL LOOP STE 120
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5741
Mailing Address - Country:US
Mailing Address - Phone:318-212-3738
Mailing Address - Fax:318-212-3781
Practice Address - Street 1:1811 E BERT KOUNS INDUSTRIAL LOOP STE 120
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5741
Practice Address - Country:US
Practice Address - Phone:318-212-3738
Practice Address - Fax:318-212-3781
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08539363A00000X
LAPA.20091363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1133361Medicaid
LA1133361Medicaid