MEDICARE: MS. MARLA D BEAVERS 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	PA0001291	CO
2	363AM0700X	Medical Physician Assistant	PA01721	TX
3	363AM0700X	Medical Physician Assistant	54554	CA
4	363A00000X	Physician Assistant	PA01721	TX

General Provider Information

NPI Number	:	1902876246
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARLA D BEAVERS PA-C

Provider Business Mailing Address
First Line	:	750 EUREKA ST STE A
Second Line	:
City	:	WEATHERFORD
State	:	TX
Zip	:	76086-6521
Country	:	US
Telephone Number	:	817-405-2689
Fax Number	:	817-405-2689

Provider Business Practice Location Address
First Line	:	750 EUREKA ST STE A
Second Line	:
City	:	WEATHERFORD
State	:	TX
Zip	:	76086-6521
Country	:	US
Telephone Number	:	817-550-6073
Fax Number	:	817-550-6076

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

Provider Enumeration Date	:	01/26/2006
Last Update Date	:	08/18/2022

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