Provider Demographics
NPI:1114479607
Name:GILBERT, BETHANY
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:GILBERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 LAURISTON ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-3728
Mailing Address - Country:US
Mailing Address - Phone:610-750-3391
Mailing Address - Fax:
Practice Address - Street 1:17 W RED BANK AVE
Practice Address - Street 2:#203
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-1630
Practice Address - Country:US
Practice Address - Phone:856-848-8242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-31
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00414100363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant