Provider Demographics
NPI:1467778027
Name:WISOTZKEY, BETHANY LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:BETHANY
Middle Name:LEE
Last Name:WISOTZKEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:LEE
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5371
Mailing Address - Street 2:818 RC
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145
Mailing Address - Country:US
Mailing Address - Phone:206-987-2000
Mailing Address - Fax:
Practice Address - Street 1:4800 SAND POINT WAY NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-3901
Practice Address - Country:US
Practice Address - Phone:206-987-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD603422112080P0202X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022228100Medicaid
WA1467778027Medicaid