Provider Demographics
NPI:1336264332
Name:BEAVERS, KATHY Y (PA)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:Y
Last Name:BEAVERS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 S NEW BALLAS RD
Mailing Address - Street 2:SUITE 2300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8219
Mailing Address - Country:US
Mailing Address - Phone:314-251-6394
Mailing Address - Fax:314-251-4235
Practice Address - Street 1:607 S NEW BALLAS RD
Practice Address - Street 2:SUITE 2300
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8219
Practice Address - Country:US
Practice Address - Phone:314-251-6394
Practice Address - Fax:314-251-4235
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004008952363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000097150Medicare PIN