Provider Demographics
NPI:1487843322
Name:TAYLOR-SPILLETT, BETHANY L (PA-C)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:L
Last Name:TAYLOR-SPILLETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:L
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3340 E. GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-302-2100
Mailing Address - Fax:208-302-2125
Practice Address - Street 1:4400 E FLAMINGO AVE
Practice Address - Street 2:STE 200
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687
Practice Address - Country:US
Practice Address - Phone:208-302-2100
Practice Address - Fax:208-302-2125
Is Sole Proprietor?:No
Enumeration Date:2007-10-16
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-852363AM0700X
ORPA01283363AM0700X
IDPA-1573363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR121087Medicare PIN