Provider Demographics
NPI:1174596746
Name:EASON, PHYLLIS (MD)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:EASON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2168
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58107-2168
Mailing Address - Country:US
Mailing Address - Phone:701-234-2119
Mailing Address - Fax:
Practice Address - Street 1:100 4TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1929
Practice Address - Country:US
Practice Address - Phone:701-234-3100
Practice Address - Fax:701-234-3120
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0439262084P0800X
WI719252084P0800X
MO20150426892084P0800X
WAMD614991662084P0800X
CAC1702322084P0800X
NDPT129122084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND18207Medicaid
MN1174596746Medicaid
GAF61845Medicare UPIN
26BDGSRMedicare PIN
NDN719014Medicare UPIN
ND18207Medicaid