Basic Information
| Provider Information | |||||||||
| NPI: | 1275053514 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEAUCHAMP | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | DENISE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VAIL, FREEBORN | ||||||||
| OtherFirstName: | ANGELA | ||||||||
| OtherMiddleName: | DENISE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 421 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990190421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667472455 | ||||||||
| FaxNumber: | 5092277070 | ||||||||
| Practice Location | |||||||||
| Address1: | 1402 S GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992035001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094558220 | ||||||||
| FaxNumber: | 5094559172 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2017 | ||||||||
| LastUpdateDate: | 04/16/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | PA60769549 | WA | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 363A00000X | PA60769549 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.