Provider Demographics
NPI:1487655338
Name:BETHMANN, CHARLES N (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:N
Last Name:BETHMANN
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:1111 BENFIELD BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MILLERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21108-3002
Mailing Address - Country:US
Mailing Address - Phone:410-729-5100
Mailing Address - Fax:410-729-5156
Practice Address - Street 1:115 SALLITT DR
Practice Address - Street 2:SUITE E
Practice Address - City:STEVENSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21666-2156
Practice Address - Country:US
Practice Address - Phone:410-643-7800
Practice Address - Fax:410-643-7568
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2011-01-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MD010207M14363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG00114010207M14Medicare ID - Type Unspecified
MD227L151589ZBUKMedicare PIN
MDS88124Medicare UPIN