Provider Demographics
NPI:1093238909
Name:BEANE, KATHRYN JEAN (PA-C, RD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:JEAN
Last Name:BEANE
Suffix:
Gender:F
Credentials:PA-C, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 SOUTH SHORE CENTER #115
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-5724
Mailing Address - Country:US
Mailing Address - Phone:562-964-8815
Mailing Address - Fax:
Practice Address - Street 1:5575 W LAS POSITAS BLVD STE 320
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-5804
Practice Address - Country:US
Practice Address - Phone:925-460-8167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-23
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA59588363AM0700X
CA1072873133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered