Healthcare Provider Details

I. General information

NPI: 1538535984
Provider Name (Legal Business Name): TINA BEATTY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2015
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 KANAWHA TER
SAINT ALBANS WV
25177-2750
US

IV. Provider business mailing address

97 GREAT TEAYS BLVD STE 6
SCOTT DEPOT WV
25560-9816
US

V. Phone/Fax

Practice location:
  • Phone: 304-201-1130
  • Fax: 304-201-1134
Mailing address:
  • Phone: 304-757-6999
  • Fax: 304-201-5019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.004403
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number712
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: