Healthcare Provider Details

I. General information

NPI: 1902858350
Provider Name (Legal Business Name): KEVIN BEAVER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 08/05/2022
Certification Date: 08/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6225 HUMPHREYS BLVD
MEMPHIS TN
38120-2373
US

IV. Provider business mailing address

PO BOX 945575
ATLANTA GA
30394-5575
US

V. Phone/Fax

Practice location:
  • Phone: 901-227-9000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN 123038
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPN 10844
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: