Provider Demographics
NPI:1801471941
Name:BEVERS, PAIGE DANIELLE (PA)
Entity type:Individual
Prefix:
First Name:PAIGE
Middle Name:DANIELLE
Last Name:BEVERS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:PAIGE
Other - Middle Name:DANIELLE
Other - Last Name:REYNEBEAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:100 THEDA CLARK MEDICAL PLZ
Mailing Address - Street 2:STE 400
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-2763
Mailing Address - Country:US
Mailing Address - Phone:920-725-4527
Mailing Address - Fax:
Practice Address - Street 1:100 THEDA CLARK MEDICAL PLZ STE 400
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2763
Practice Address - Country:US
Practice Address - Phone:920-725-4527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-10
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5461-23208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery