Healthcare Provider Details

I. General information

NPI: 1003720285
Provider Name (Legal Business Name): JUSTIN RYAN BEASLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 COMMERCE ST
CLINTON NC
28328
US

IV. Provider business mailing address

107 JAMES ST
SALEMBURG NC
28385-8669
US

V. Phone/Fax

Practice location:
  • Phone: 910-379-6175
  • Fax:
Mailing address:
  • Phone: 910-379-6175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License NumberP104366
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: