MEDICARE: PAIGE ELIZABETH BEVERLY 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	2646	OK
2	363AM0700X	Medical Physician Assistant	2646	OK
3	207N00000X	Dermatology Physician	PA2646	OK

General Provider Information

NPI Number	:	1962869313
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAIGE ELIZABETH BEVERLY PA-C

Provider Business Mailing Address
First Line	:	13100 N WESTERN AVE STE 301
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73114-1432
Country	:	US
Telephone Number	:	405-947-6647
Fax Number	:	405-948-6647

Provider Business Practice Location Address
First Line	:	13100 N WESTERN AVE STE 301
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73114-1432
Country	:	US
Telephone Number	:	405-947-6647
Fax Number	:

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

Provider Enumeration Date	:	01/15/2016
Last Update Date	:	10/17/2018

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