Basic Information
| Provider Information | |||||||||
| NPI: | 1255829768 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEAL | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13808 PROFESSIONAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | HUNTERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280787948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043774009 | ||||||||
| FaxNumber: | 7046026563 | ||||||||
| Practice Location | |||||||||
| Address1: | 2015 RANDOLPH RD STE 208 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282071200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043774009 | ||||||||
| FaxNumber: | 7043777406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2018 | ||||||||
| LastUpdateDate: | 04/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-07768 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.