Provider Demographics
NPI: | 1528388709 |
---|---|
Name: | BEAUPRE, STACY BRITTANY (PA) |
Entity Type: | Individual |
Prefix: | MS |
First Name: | STACY |
Middle Name: | BRITTANY |
Last Name: | BEAUPRE |
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: | 55 HAZARD AVE UNIT 1 |
Mailing Address - Street 2: | |
Mailing Address - City: | ENFIELD |
Mailing Address - State: | CT |
Mailing Address - Zip Code: | 06082-3813 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 860-745-9911 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 55 HAZARD AVE |
Practice Address - Street 2: | |
Practice Address - City: | ENFIELD |
Practice Address - State: | CT |
Practice Address - Zip Code: | 06082-3813 |
Practice Address - Country: | US |
Practice Address - Phone: | 860-745-9911 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2010-06-10 |
Last Update Date: | 2022-10-17 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CT | 4083 | 363A00000X, 363A00000X |
NM | 2010-0025 | 363AM0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | |
No | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | P56630 | Medicare UPIN | |
TX | S06142 | Medicare UPIN |