Provider Demographics
NPI:1215245287
Name:BEVERLY, JAMES MARC (PA-C)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:MARC
Last Name:BEVERLY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:MR
Other - First Name:MARC
Other - Middle Name:
Other - Last Name:BEVERLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:6101 IMPERATA ST NE
Mailing Address - Street 2:#2422
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111
Mailing Address - Country:US
Mailing Address - Phone:505-264-8364
Mailing Address - Fax:888-823-2280
Practice Address - Street 1:6101 IMPERATA ST NE
Practice Address - Street 2:#2422
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111
Practice Address - Country:US
Practice Address - Phone:505-264-8364
Practice Address - Fax:888-823-2280
Is Sole Proprietor?:No
Enumeration Date:2010-09-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2001-PA16363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant