MEDICARE: BRADLEY J. BEATTIE III 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
1	363A00000X	Physician Assistant	001135	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	001135	OTHER	ID	LICENSE

General Provider Information

NPI Number	:	1841286622
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRADLEY J. BEATTIE III PA-C

Provider Business Mailing Address
First Line	:	1208 N LINCOLN ST
Second Line	:
City	:	KNOXVILLE
State	:	IA
Zip	:	50138-3421
Country	:	US
Telephone Number	:	641-828-3832
Fax Number	:	641-828-3820

Provider Business Practice Location Address
First Line	:	1208 N LINCOLN ST
Second Line	:
City	:	KNOXVILLE
State	:	IA
Zip	:	50138-3421
Country	:	US
Telephone Number	:	641-828-3832
Fax Number	:	641-828-3820

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2005
Last Update Date	:	08/04/2021

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