Provider Demographics
NPI:1407431950
Name:MARTIN, BETHANY
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:MARTIN
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 1:28891 STATE ROUTE 172
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:44427-9732
Mailing Address - Country:US
Mailing Address - Phone:330-692-0239
Mailing Address - Fax:
Practice Address - Street 1:141 N FORGE ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44304-1407
Practice Address - Country:US
Practice Address - Phone:330-375-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-16
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.007192363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant