Provider Demographics
NPI:1922805456
Name:BEASLEY, MAKENZIE JORDAN (PA)
Entity type:Individual
Prefix:
First Name:MAKENZIE
Middle Name:JORDAN
Last Name:BEASLEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4705 UNIVERSITY DR BLDG 700
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-3489
Mailing Address - Country:US
Mailing Address - Phone:919-464-5906
Mailing Address - Fax:
Practice Address - Street 1:2076 VETERANS PKWY STE 230
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-5303
Practice Address - Country:US
Practice Address - Phone:919-553-5711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-03
Last Update Date:2025-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-15419363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty