Provider Demographics
NPI:1114245313
Name:BEASTROM, NICHOLAS (AA)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:
Last Name:BEASTROM
Suffix:
Gender:M
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6780 MAYFIELD ROAD
Mailing Address - Street 2:
Mailing Address - City:MAYFILED HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44124-2212
Mailing Address - Country:US
Mailing Address - Phone:440-312-4500
Mailing Address - Fax:
Practice Address - Street 1:6780 MAYFIELD ROAD
Practice Address - Street 2:
Practice Address - City:MAYFILED HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44124-2212
Practice Address - Country:US
Practice Address - Phone:440-312-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH67.000167367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant