Provider Demographics
NPI:1841286622
Name:BEATTIE, BRADLEY J III (PA-C)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:J
Last Name:BEATTIE
Suffix:III
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 1:1208 N LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:50138-3421
Mailing Address - Country:US
Mailing Address - Phone:641-828-3832
Mailing Address - Fax:641-828-3820
Practice Address - Street 1:1208 N LINCOLN ST
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:IA
Practice Address - Zip Code:50138-3421
Practice Address - Country:US
Practice Address - Phone:641-828-3832
Practice Address - Fax:641-828-3820
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001135363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID001135OtherLICENSE
IAS29710Medicare UPIN
IA560910017Medicare Oscar/Certification