Healthcare Provider Details

I. General information

NPI: 1851939482
Provider Name (Legal Business Name): RYAN THOMAS BEASON SO/IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2019
Last Update Date: 12/13/2019
Certification Date: 12/13/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2D MARINE RAIDER BATTALION
FPO AA
28542
US

IV. Provider business mailing address

109 FOGGY RIVER WAY
JACKSONVILLE NC
28540-8074
US

V. Phone/Fax

Practice location:
  • Phone: 910-440-7704
  • Fax:
Mailing address:
  • Phone: 217-254-0712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: