Provider Demographics
NPI:1114781747
Name:PARK, BETHANY LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:LYNN
Last Name:PARK
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 1:1521 ROYAL OAK ST SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-2711
Mailing Address - Country:US
Mailing Address - Phone:989-277-6478
Mailing Address - Fax:
Practice Address - Street 1:27177 LAHSER RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-4714
Practice Address - Country:US
Practice Address - Phone:989-277-6478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601012241363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant