Provider Demographics
NPI:1467127779
Name:BEATTY, CAMERON WADE
Entity Type:Individual
Prefix:MR
First Name:CAMERON
Middle Name:WADE
Last Name:BEATTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 JUNEBERRY CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-3284
Mailing Address - Country:US
Mailing Address - Phone:704-562-8170
Mailing Address - Fax:
Practice Address - Street 1:2310 JUNEBERRY CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-3284
Practice Address - Country:US
Practice Address - Phone:704-562-8170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor