Provider Demographics
NPI:1255974655
Name:BEVERLY, KAITLYN B (PA-C)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:B
Last Name:BEVERLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:T
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 SINGLETON RIDGE ROAD
Mailing Address - Street 2:ATTENTION PATIENT ACCOUNTING
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-9142
Mailing Address - Country:US
Mailing Address - Phone:843-234-6946
Mailing Address - Fax:
Practice Address - Street 1:620 SINGLETON RIDGE ROAD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-9154
Practice Address - Country:US
Practice Address - Phone:843-347-7300
Practice Address - Fax:843-347-8459
Is Sole Proprietor?:No
Enumeration Date:2019-10-18
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4261PAMedicaid