Provider Demographics
NPI:1477651743
Name:BEAUMONT, BENJAMIN F (PA)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:F
Last Name:BEAUMONT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:MS
Other - First Name:CATHRYN
Other - Middle Name:A
Other - Last Name:SALLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:34700 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4500
Mailing Address - Country:US
Mailing Address - Phone:800-767-4411
Mailing Address - Fax:262-646-3158
Practice Address - Street 1:4600 W SCHROEDER DR
Practice Address - Street 2:
Practice Address - City:BROWN DEER
Practice Address - State:WI
Practice Address - Zip Code:53223-1469
Practice Address - Country:US
Practice Address - Phone:800-767-4411
Practice Address - Fax:414-797-0804
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO118266363AS0400X
WI3997-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOS77398Medicare UPIN