Provider Demographics
NPI:1982365821
Name:BEAVER, ANTHONY JOHN
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:JOHN
Last Name:BEAVER
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 1:12141 BROOKHURST ST STE 201
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-2865
Mailing Address - Country:US
Mailing Address - Phone:657-261-7140
Mailing Address - Fax:
Practice Address - Street 1:12141 BROOKHURST ST STE 201
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-2865
Practice Address - Country:US
Practice Address - Phone:657-261-7140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-03
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-BZAHOQ175T00000X
175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist