Provider Demographics
NPI:1740239862
Name:BEACH, KENNETH BRYAN (CRNA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:BRYAN
Last Name:BEACH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13646 240TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST UNION
Mailing Address - State:IA
Mailing Address - Zip Code:52175-9419
Mailing Address - Country:US
Mailing Address - Phone:563-422-5386
Mailing Address - Fax:
Practice Address - Street 1:112 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:WEST UNION
Practice Address - State:IA
Practice Address - Zip Code:52175-1022
Practice Address - Country:US
Practice Address - Phone:563-422-9738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAD-119341367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered