Healthcare Provider Details

I. General information

NPI: 1457664625
Provider Name (Legal Business Name): KIANA L BEAUDIN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2010
Last Update Date: 02/01/2022
Certification Date: 02/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

S2845 WHITE EAGLE RD
BARABOO WI
53913-9064
US

IV. Provider business mailing address

S2845 WHITE EAGLE RD
BARABOO WI
53913-9064
US

V. Phone/Fax

Practice location:
  • Phone: 608-355-1240
  • Fax: 608-355-9643
Mailing address:
  • Phone: 608-355-1240
  • Fax: 608-355-9643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2631-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: