Provider Demographics
NPI:1346809589
Name:WHITNEY, BETHANY TERESA (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:TERESA
Last Name:WHITNEY
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 WATERCHASE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-2110
Mailing Address - Country:US
Mailing Address - Phone:413-446-7084
Mailing Address - Fax:
Practice Address - Street 1:85 SEYMOUR ST STE 1000
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5564
Practice Address - Country:US
Practice Address - Phone:860-246-2571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-11
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4575363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT346809589Medicaid