Healthcare Provider Details

I. General information

NPI: 1801624788
Provider Name (Legal Business Name): SELENA BEAL PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2024
Last Update Date: 12/30/2024
Certification Date: 12/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2709 BLUE RIDGE RD
RALEIGH NC
27607-0113
US

IV. Provider business mailing address

2709 BLUE RIDGE RD STE 320
RALEIGH NC
27607-6462
US

V. Phone/Fax

Practice location:
  • Phone: 919-876-7692
  • Fax:
Mailing address:
  • Phone: 919-876-7692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110010233
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-14505
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: