Provider Demographics
NPI:1912003716
Name:BEASON, MIRANDA KATE (RD)
Entity Type:Individual
Prefix:MS
First Name:MIRANDA
Middle Name:KATE
Last Name:BEASON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 616
Mailing Address - Street 2:
Mailing Address - City:PONCHA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81242-0616
Mailing Address - Country:US
Mailing Address - Phone:719-530-2293
Mailing Address - Fax:719-530-2232
Practice Address - Street 1:448 E 1ST ST
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CO
Practice Address - Zip Code:81201-2804
Practice Address - Country:US
Practice Address - Phone:719-530-2293
Practice Address - Fax:719-530-2232
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE00934419133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO806260Medicare PIN