Provider Demographics
NPI:1255300091
Name:BEEBOUT, LANCE JEFFREY (PAC)
Entity Type:Individual
Prefix:MR
First Name:LANCE
Middle Name:JEFFREY
Last Name:BEEBOUT
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 17TH AVE E STE 101
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-3734
Mailing Address - Country:US
Mailing Address - Phone:320-762-1144
Mailing Address - Fax:320-762-1935
Practice Address - Street 1:111 17TH AVE E STE 101
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-3734
Practice Address - Country:US
Practice Address - Phone:320-762-1144
Practice Address - Fax:320-762-1935
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9887363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1255300091Medicaid
MB1112060OtherDEA
MN970005487Medicare UPIN
MB1112060OtherDEA