Provider Demographics
NPI:1518593219
Name:BETHUNE, JOHN MARVIN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MARVIN
Last Name:BETHUNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 601843
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1843
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1530 PROVIDENCE RD S
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-8313
Practice Address - Country:US
Practice Address - Phone:704-627-8365
Practice Address - Fax:704-627-8366
Is Sole Proprietor?:No
Enumeration Date:2020-03-14
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN.23980APRN363L00000X
NC5014484363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner