Provider Demographics
NPI:1659364735
Name:BEAVER, JAMES E JR (PAC)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:E
Last Name:BEAVER
Suffix:JR
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 DOGWOOD CT
Mailing Address - Street 2:
Mailing Address - City:DANIELS
Mailing Address - State:WV
Mailing Address - Zip Code:25832-9202
Mailing Address - Country:US
Mailing Address - Phone:304-763-5121
Mailing Address - Fax:304-469-1518
Practice Address - Street 1:134 MEDICAL PL
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:WV
Practice Address - Zip Code:25813-8977
Practice Address - Country:US
Practice Address - Phone:304-255-1080
Practice Address - Fax:304-255-1082
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV779363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0034323000Medicaid
WVBEPA26673Medicare ID - Type Unspecified
WVQ66966Medicare UPIN