Provider Demographics
NPI:1912525932
Name:BEINTEMA, MARYAM MICHELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:MICHELLE
Last Name:BEINTEMA
Suffix:
Gender:F
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 1:135 OAKMONT DR
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-5085
Mailing Address - Country:US
Mailing Address - Phone:847-477-0391
Mailing Address - Fax:
Practice Address - Street 1:135 OAKMONT DR
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-5085
Practice Address - Country:US
Practice Address - Phone:847-477-0391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-07
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085008470363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant