Provider Demographics
NPI:1508899485
Name:BEVERS, MIKE
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:BEVERS
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:MIKE
Other - Middle Name:JESSE
Other - Last Name:BEVERS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:2016 GILPIN AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19806-2214
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18947 JOHN WILLMS HWY
Practice Address - Street 2:
Practice Address - City:REHOBOTH BEACH
Practice Address - State:DE
Practice Address - Zip Code:19971-4474
Practice Address - Country:US
Practice Address - Phone:302-703-6585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000987363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant