Basic Information
| Provider Information | |||||||||
| NPI: | 1508317702 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEAVER | ||||||||
| FirstName: | ABIGAIL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | THOMAS | ||||||||
| OtherFirstName: | ABIGAIL | ||||||||
| OtherMiddleName: | L | ||||||||
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| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 164 N BROADWAY | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543032728 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2845 GREENBRIER RD | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543116519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202888000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2016 | ||||||||
| LastUpdateDate: | 02/13/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 153064 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.