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NPI Code Detail

MEDICARE: MS. JACQUELYN RAY BEEMER PA-C

MEDICARE: MS. JACQUELYN RAY BEEMER PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207N00000XDermatology Physician10002412AIN
2363A00000XPhysician Assistant10002412AIN

General Provider Information

NPI Number : 1396248415
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. JACQUELYN RAY BEEMER PA-C
Provider Business Mailing Address
First Line : 5650 COVENTRY LN
Second Line :
City : FORT WAYNE
State : IN
Zip : 46804-7140
Country : US
Telephone Number : 260-436-9696
Fax Number :
Provider Business Practice Location Address
First Line : 5650 COVENTRY LN
Second Line :
City : FORT WAYNE
State : IN
Zip : 46804-7140
Country : US
Telephone Number : 260-436-9696
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/15/2018
Last Update Date : 03/15/2018

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