Provider Demographics
NPI:1295927747
Name:BEATTY, NICHOLAS ROBERT (PA)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ROBERT
Last Name:BEATTY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22182 BARTON RD
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5033
Mailing Address - Country:US
Mailing Address - Phone:909-422-0422
Mailing Address - Fax:
Practice Address - Street 1:22182 BARTON RD
Practice Address - Street 2:
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-5033
Practice Address - Country:US
Practice Address - Phone:909-422-0422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-17
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14337363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical