Provider Demographics
NPI:1487321782
Name:EASLEY, EDWARD RAY JR (MBE)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:RAY
Last Name:EASLEY
Suffix:JR
Gender:M
Credentials:MBE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8608 W HEMLOCK ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53224-4042
Mailing Address - Country:US
Mailing Address - Phone:414-788-1727
Mailing Address - Fax:
Practice Address - Street 1:8608 W HEMLOCK ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53224-4042
Practice Address - Country:US
Practice Address - Phone:414-788-1727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIE2402367714503172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver