Healthcare Provider Details

I. General information

NPI: 1174141238
Provider Name (Legal Business Name): KAITLIN M BEADLES PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2020
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9305 W THOMAS RD STE 370
PHOENIX AZ
85037-3367
US

IV. Provider business mailing address

645 E MISSOURI AVE STE 280
PHOENIX AZ
85012-1349
US

V. Phone/Fax

Practice location:
  • Phone: 602-266-5678
  • Fax: 602-264-5646
Mailing address:
  • Phone: 602-264-9100
  • Fax: 602-264-9101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8161
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: