Basic Information
| Provider Information | |||||||||
| NPI: | 1245434844 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEAUCHAMP | ||||||||
| FirstName: | BRANDY | ||||||||
| MiddleName: | LA'SHAY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 RIO GRANDE ST | ||||||||
| Address2: | SUITE 340 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787011137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123248960 | ||||||||
| FaxNumber: | 5123248962 | ||||||||
| Practice Location | |||||||||
| Address1: | 441 HWY 71 W | ||||||||
| Address2: | SUITE C | ||||||||
| City: | BASTROP | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786023931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123040311 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2007 | ||||||||
| LastUpdateDate: | 01/31/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N4288 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 208594603 | 05 | TX | MEDICAID | 208594602 | 05 | TX | MEDICAID |