Provider Demographics
NPI:1598597627
Name:EAGLE, RICHARD MARVIN (SA-C)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:MARVIN
Last Name:EAGLE
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:MR
Other - First Name:RICHARD
Other - Middle Name:M
Other - Last Name:EAGLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SA-C
Mailing Address - Street 1:362 GULF BREEZE PKWY # 279
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32561-4492
Mailing Address - Country:US
Mailing Address - Phone:702-285-8989
Mailing Address - Fax:
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3175
Practice Address - Country:US
Practice Address - Phone:207-662-2241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-16
Last Update Date:2024-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical