Healthcare Provider Details

I. General information

NPI: 1255672465
Provider Name (Legal Business Name): MICHAEL BEAUCHAINE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2013
Last Update Date: 11/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 8TH AVE SUITE 200
WEST LINN OR
97068
US

IV. Provider business mailing address

PO BOX 19070
GREEN BAY WI
54307-9070
US

V. Phone/Fax

Practice location:
  • Phone: 503-512-1212
  • Fax:
Mailing address:
  • Phone: 920-496-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA174762
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4229-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: