Provider Demographics
NPI:1003066143
Name:BEAVERS, JOHN P (NP)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:P
Last Name:BEAVERS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5717 OAKLAND DR
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-1116
Mailing Address - Country:US
Mailing Address - Phone:269-323-4473
Mailing Address - Fax:517-278-2784
Practice Address - Street 1:5717 OAKLAND DR
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-1116
Practice Address - Country:US
Practice Address - Phone:269-323-4473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-25
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704234332207P00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI500C961050OtherBCBSM
MI1003066143Medicaid
MIMI1609044Medicare PIN
MI500C961050OtherBCBSM