Provider Demographics
NPI:1790726685
Name:JEWELL, BETH A (PA-C)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:A
Last Name:JEWELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:A
Other - Last Name:ENGEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:501 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-1235
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1900 W SUMNER ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:WI
Practice Address - Zip Code:53027-9241
Practice Address - Country:US
Practice Address - Phone:262-673-1143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI919-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI970026378OtherMEDICARE RAILROAD
WI42963100Medicaid
S33137Medicare UPIN
WI0096-68655Medicare ID - Type Unspecified
WI42963100Medicaid
WI0057-32280Medicare ID - Type Unspecified
WI970026378OtherMEDICARE RAILROAD