Provider Demographics
NPI:1245223213
Name:BECKHAM, CLEO (PA)
Entity Type:Individual
Prefix:MRS
First Name:CLEO
Middle Name:
Last Name:BECKHAM
Suffix:
Gender:F
Credentials:PA
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 3755
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-0755
Mailing Address - Country:US
Mailing Address - Phone:402-354-2100
Mailing Address - Fax:402-354-2155
Practice Address - Street 1:201 RIDGE ST
Practice Address - Street 2:SUITE 214
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-4643
Practice Address - Country:US
Practice Address - Phone:712-396-4320
Practice Address - Fax:712-396-4328
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2017-05-01
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-04-10
Provider Licenses
StateLicense IDTaxonomies
IA001350363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1245223213Medicaid
NE10026480113Medicaid
IA1245223213Medicaid
IAP29489Medicare UPIN