Provider Demographics
NPI:1649780727
Name:BEAL, CHASE
Entity type:Individual
Prefix:
First Name:CHASE
Middle Name:
Last Name:BEAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 LOCHSA LOOP
Mailing Address - Street 2:
Mailing Address - City:HEYBURN
Mailing Address - State:ID
Mailing Address - Zip Code:83336-1009
Mailing Address - Country:US
Mailing Address - Phone:208-690-1092
Mailing Address - Fax:
Practice Address - Street 1:382 N OVERLAND AVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-3433
Practice Address - Country:US
Practice Address - Phone:208-678-6996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-03
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1534363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant