Provider Demographics
NPI:1760827372
Name:ELLER, BEAVER E (FNP-BC, AGACNP-BC)
Entity type:Individual
Prefix:
First Name:BEAVER
Middle Name:E
Last Name:ELLER
Suffix:
Gender:M
Credentials:FNP-BC, AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2155 MT HIGHWAY 200
Mailing Address - Street 2:
Mailing Address - City:TROUT CREEK
Mailing Address - State:MT
Mailing Address - Zip Code:59874-9540
Mailing Address - Country:US
Mailing Address - Phone:406-334-3408
Mailing Address - Fax:
Practice Address - Street 1:520 N 3RD AVE
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1507
Practice Address - Country:US
Practice Address - Phone:208-263-0649
Practice Address - Fax:208-265-6743
Is Sole Proprietor?:No
Enumeration Date:2013-05-09
Last Update Date:2022-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP6085682363L00000X
GU22NP01363LF0000X
MT1251200363LF0000X
GU22R030363LG0600X
IDNP-1621A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology