Healthcare Provider Details

I. General information

NPI: 1821097510
Provider Name (Legal Business Name): JOSHUA JEREMIAH BEARDSLEY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 01/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S HERLONG AVE SUITE B
ROCK HILL SC
29732-3399
US

IV. Provider business mailing address

200 S HERLONG AVE SUITE B
ROCK HILL SC
29732-3399
US

V. Phone/Fax

Practice location:
  • Phone: 803-327-8500
  • Fax: 803-327-8505
Mailing address:
  • Phone: 803-327-8500
  • Fax: 803-327-8505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number103940
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA936
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: