Provider Demographics
NPI:1891701629
Name:BEVAN, ELEANOR (PA-C)
Entity type:Individual
Prefix:
First Name:ELEANOR
Middle Name:
Last Name:BEVAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELEANOR
Other - Middle Name:Z
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:51 NORTH 39TH ST
Mailing Address - Street 2:MOB, SUITE 300
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104
Mailing Address - Country:US
Mailing Address - Phone:215-662-8099
Mailing Address - Fax:
Practice Address - Street 1:51 NORTH 39TH ST
Practice Address - Street 2:MOB, SUITE 300
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-662-8099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA050875363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA147346PAGMedicare PIN