Provider Demographics
NPI:1821792854
Name:BEACH, BRIAN ANDREW (FNP-C)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:ANDREW
Last Name:BEACH
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5715 EDEN ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-2025
Mailing Address - Country:US
Mailing Address - Phone:208-339-3620
Mailing Address - Fax:
Practice Address - Street 1:850 YELLOWSTONE AVE STE A
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4415
Practice Address - Country:US
Practice Address - Phone:208-239-8065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-27
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTNUR-APRN-LIC-213661363LF0000X
ID57692363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily