Basic Information
Provider Information | |||||||||
NPI: | 1245223213 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BECKHAM | ||||||||
FirstName: | CLEO | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3755 | ||||||||
Address2: |   | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 681030755 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4023542100 | ||||||||
FaxNumber: | 4023542155 | ||||||||
Practice Location | |||||||||
Address1: | 201 RIDGE ST | ||||||||
Address2: | SUITE 214 | ||||||||
City: | COUNCIL BLUFFS | ||||||||
State: | IA | ||||||||
PostalCode: | 515034643 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7123964320 | ||||||||
FaxNumber: | 7123964328 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/25/2005 | ||||||||
LastUpdateDate: | 05/01/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 03/27/2006 | ||||||||
NPIReactivationDate: | 04/10/2006 | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 001350 | IA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 1245223213 | 05 | IA |   | MEDICAID | 10026480113 | 05 | NE |   | MEDICAID |