Provider Demographics
NPI:1316199003
Name:BEVERLY, LARA JENNIFER (PA)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:JENNIFER
Last Name:BEVERLY
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 1:1136 E GRANDE BLVD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-3982
Mailing Address - Country:US
Mailing Address - Phone:903-592-5601
Mailing Address - Fax:903-595-3304
Practice Address - Street 1:1339 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SULPHUR SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75482-4895
Practice Address - Country:US
Practice Address - Phone:903-951-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-14
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05919363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX210066104Medicaid
TX210066106Medicaid
TX8Y9005OtherBCBS
TX210066104Medicaid
TXP01246214OtherRAIL ROAD
TX75-2616977-001OtherTRICARE
TX8853NAOtherBCBS
TXP01246214OtherRAIL ROAD
TXP01304434OtherRAIL ROAD
75-2616977-002OtherTRICARE
TX309988YNSXMedicare PIN
TX75-0818167-022OtherTRICARE
TX75-2616977-028OtherTRICARE