Provider Demographics
NPI:1225242100
Name:BECKUM, MICHAEL T (FNP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:BECKUM
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 S. GLENBROOK
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901
Mailing Address - Country:US
Mailing Address - Phone:662-229-5367
Mailing Address - Fax:
Practice Address - Street 1:840 N OAK AVE
Practice Address - Street 2:
Practice Address - City:RULEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38771-3227
Practice Address - Country:US
Practice Address - Phone:662-756-2711
Practice Address - Fax:662-756-4114
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR798671363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00123578Medicaid
MSP24879Medicare UPIN
MS00123578Medicaid