Provider Demographics
NPI:1104921782
Name:BEAVERS, NOLAN JACKSON (MD,)
Entity type:Individual
Prefix:DR
First Name:NOLAN
Middle Name:JACKSON
Last Name:BEAVERS
Suffix:
Gender:M
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2337 G ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:66935-2463
Mailing Address - Country:US
Mailing Address - Phone:785-527-2217
Mailing Address - Fax:785-527-5929
Practice Address - Street 1:2337 G ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:KS
Practice Address - Zip Code:66935-2463
Practice Address - Country:US
Practice Address - Phone:785-527-2217
Practice Address - Fax:785-527-5929
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-30225207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100642760CMedicaid
KS100642760CMedicaid
KS104880Medicare ID - Type Unspecified