Provider Demographics
NPI:1114122728
Name:BECKLEY, MICHAEL RYAN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:RYAN
Last Name:BECKLEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10415 N 10TH ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-8527
Mailing Address - Country:US
Mailing Address - Phone:517-896-3065
Mailing Address - Fax:
Practice Address - Street 1:13838 S 46TH PL STE 320
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-7804
Practice Address - Country:US
Practice Address - Phone:480-759-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3631363A00000X
MI5601005425363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant