Provider Demographics
NPI:1174141238
Name:BEADLES, KAITLIN M (PA)
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:M
Last Name:BEADLES
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:645 E MISSOURI AVE STE 280
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-1349
Mailing Address - Country:US
Mailing Address - Phone:602-264-9100
Mailing Address - Fax:602-264-9101
Practice Address - Street 1:9305 W THOMAS RD STE 370
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-3367
Practice Address - Country:US
Practice Address - Phone:602-266-5678
Practice Address - Fax:602-264-5646
Is Sole Proprietor?:No
Enumeration Date:2020-07-06
Last Update Date:2023-09-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ8161363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ156602Medicaid
AZZ120390OtherPTAN