Basic Information
| Provider Information | |||||||||
| NPI: | 1477651743 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEAUMONT | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SALLA | ||||||||
| OtherFirstName: | CATHRYN | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | P.A. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 34700 VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | OCONOMOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530664500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007674411 | ||||||||
| FaxNumber: | 2626463158 | ||||||||
| Practice Location | |||||||||
| Address1: | 4600 W SCHROEDER DR | ||||||||
| Address2: | |||||||||
| City: | BROWN DEER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532231469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007674411 | ||||||||
| FaxNumber: | 4147970804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 11/13/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 118266 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 3997-23 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.