Provider Demographics
NPI:1225283963
Name:WOOD, BETHANY M (PA)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:M
Last Name:WOOD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5615 DEAUVILLE STE 220
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79706-2707
Mailing Address - Country:US
Mailing Address - Phone:325-226-3503
Mailing Address - Fax:
Practice Address - Street 1:5615 DEAUVILLE STE 220
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79706-2707
Practice Address - Country:US
Practice Address - Phone:432-221-4755
Practice Address - Fax:432-686-0664
Is Sole Proprietor?:No
Enumeration Date:2008-11-21
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05955363A00000X, 363AM0700X, 363AS0400X
MN12533363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L9846Medicare PIN