Healthcare Provider Details

I. General information

NPI: 1659364735
Provider Name (Legal Business Name): JAMES E BEAVER JR. PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 02/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 MEDICAL PL
BEAVER WV
25813-8977
US

IV. Provider business mailing address

208 DOGWOOD CT
DANIELS WV
25832-9202
US

V. Phone/Fax

Practice location:
  • Phone: 304-255-1080
  • Fax: 304-255-1082
Mailing address:
  • Phone: 304-763-5121
  • Fax: 304-469-1518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number779
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: