Provider Demographics
NPI:1114180239
Name:BEVERLY, PETER A (CRNA)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:A
Last Name:BEVERLY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 932925
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-2925
Mailing Address - Country:US
Mailing Address - Phone:800-364-9216
Mailing Address - Fax:423-892-5838
Practice Address - Street 1:303 PARKWAY DRIVE NE
Practice Address - Street 2:PMB 404
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1212
Practice Address - Country:US
Practice Address - Phone:404-265-4424
Practice Address - Fax:404-265-3894
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN127632367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
1114180239OtherTRICARE
GA670634888FMedicaid
GA670634888EMedicaid
GA202I431613Medicare PIN
GA670634888FMedicaid