Provider Demographics
NPI:1255382354
Name:BEAVER, JOHN D (NP)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:BEAVER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 N BROWN ST
Mailing Address - Street 2:
Mailing Address - City:CHADBOURN
Mailing Address - State:NC
Mailing Address - Zip Code:28431-1716
Mailing Address - Country:US
Mailing Address - Phone:910-654-1701
Mailing Address - Fax:910-654-5701
Practice Address - Street 1:110 N BROWN ST
Practice Address - Street 2:
Practice Address - City:CHADBOURN
Practice Address - State:NC
Practice Address - Zip Code:28431-1716
Practice Address - Country:US
Practice Address - Phone:910-654-1701
Practice Address - Fax:910-654-5701
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC005000684363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC344634AMedicaid
NC344634CMedicaid
NC348909Medicare PIN