Provider Demographics
NPI:1003232265
Name:CADWALLADER, BEVERLY JEAN (PA-C)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:JEAN
Last Name:CADWALLADER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BEVERLY
Other - Middle Name:
Other - Last Name:GALLATI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1129 LAKE OCONEE PKWY STE 104
Mailing Address - Street 2:
Mailing Address - City:EATONTON
Mailing Address - State:GA
Mailing Address - Zip Code:31024-9581
Mailing Address - Country:US
Mailing Address - Phone:762-220-1962
Mailing Address - Fax:762-220-1961
Practice Address - Street 1:1129 LAKE OCONEE PKWY STE 104
Practice Address - Street 2:
Practice Address - City:EATONTON
Practice Address - State:GA
Practice Address - Zip Code:31024-9581
Practice Address - Country:US
Practice Address - Phone:762-220-1962
Practice Address - Fax:762-220-1961
Is Sole Proprietor?:No
Enumeration Date:2014-03-12
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8792363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical