=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972890093
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEGAN BEARMAN PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2011
-----------------------------------------------------
Last Update Date | 11/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3640 NEW VISION DR SUITE A
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46845-1717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-482-4440
-----------------------------------------------------
Fax | 260-482-4442
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3640 NEW VISION DR SUITE A
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46845-1717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-482-4440
-----------------------------------------------------
Fax | 260-482-4442
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 10001286A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------