Provider Demographics
NPI:1255470100
Name:MCNEIL, BEVERLY LAVON (PAC)
Entity Type:Individual
Prefix:MS
First Name:BEVERLY
Middle Name:LAVON
Last Name:MCNEIL
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1265 EDDY ST
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-9216
Mailing Address - Country:US
Mailing Address - Phone:360-385-9730
Mailing Address - Fax:
Practice Address - Street 1:530 BOGACHIEL WAY
Practice Address - Street 2:
Practice Address - City:FORKS
Practice Address - State:WA
Practice Address - Zip Code:98331-9120
Practice Address - Country:US
Practice Address - Phone:360-374-6271
Practice Address - Fax:360-374-6238
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004657363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2334MCOtherREGENCE
WA8389975Medicaid
WA0188321OtherL&I
WA8389975Medicaid