Provider Demographics
NPI:1104894997
Name:BEBEAU, FREDERICK JOSEPH (PA)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:JOSEPH
Last Name:BEBEAU
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3650 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77707-2216
Mailing Address - Country:US
Mailing Address - Phone:409-838-0346
Mailing Address - Fax:409-924-4951
Practice Address - Street 1:3650 LAUREL ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77707-2216
Practice Address - Country:US
Practice Address - Phone:409-838-0346
Practice Address - Fax:409-924-4951
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04442363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXQ42193Medicare UPIN