Healthcare Provider Details

I. General information

NPI: 1659579860
Provider Name (Legal Business Name): GAYLA A BEAVER R MR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11300 FINANCIAL CENTRE PKWY SUITE 400
LITTLE ROCK AR
72211-3746
US

IV. Provider business mailing address

149 LILY DR
MAUMELLE AR
72113-5831
US

V. Phone/Fax

Practice location:
  • Phone: 501-221-2502
  • Fax:
Mailing address:
  • Phone: 501-851-8426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License NumberRT66
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code2471M1202X
TaxonomyMagnetic Resonance Imaging Radiologic Technologist
License Number163898
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: