Provider Demographics
NPI:1568546596
Name:BEAUREGARD, JILL RAE (PA)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:RAE
Last Name:BEAUREGARD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:RAE
Other - Last Name:ROBERSON-BLATT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-6350
Mailing Address - Fax:239-343-6358
Practice Address - Street 1:9800 S HEALTHPARK DR STE 320
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3630
Practice Address - Country:US
Practice Address - Phone:239-343-6350
Practice Address - Fax:239-343-6358
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1444363AM0700X
FLPA9110279363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4336423OtherBLUE CROSS/BLUE SHIELD
FL102132900Medicaid
TNP01155340OtherRR MEDICARE
TN3664999Medicaid