Provider Demographics
NPI:1902858350
Name:BEAVER, KEVIN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:BEAVER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 945575
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30394-5575
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6225 HUMPHREYS BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2373
Practice Address - Country:US
Practice Address - Phone:901-227-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN 123038163W00000X
TNAPN 10844367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4081894OtherBLUE CROSS OF TN
AR99664OtherBLUE CROSS OF AR
TN3633322Medicaid
MS04573508Medicaid
TNP00127953OtherRAILROAD MEDICARE
TN3633322Medicare ID - Type Unspecified