Provider Demographics
NPI:1336622281
Name:BEASLEY, MICHAEL D JR (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:BEASLEY
Suffix:JR
Gender:M
Credentials:PA-C
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 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-1409
Mailing Address - Country:US
Mailing Address - Phone:502-272-5134
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:825 BARRET AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-1743
Practice Address - Country:US
Practice Address - Phone:502-540-7200
Practice Address - Fax:502-540-7210
Is Sole Proprietor?:No
Enumeration Date:2018-09-06
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC780363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical