Provider Demographics
NPI:1083326292
Name:BETHKE, KELCI (PA-C)
Entity Type:Individual
Prefix:
First Name:KELCI
Middle Name:
Last Name:BETHKE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 DELOZIER LN
Mailing Address - Street 2:
Mailing Address - City:ROCKWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37854-4217
Mailing Address - Country:US
Mailing Address - Phone:469-596-3420
Mailing Address - Fax:
Practice Address - Street 1:509 SE RIVERSIDE DR STE 201
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2579
Practice Address - Country:US
Practice Address - Phone:772-419-2137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-19
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9117164363AS0400X, 363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical