Provider Demographics
NPI:1568649234
Name:LUBENOW, BETHANY JANE (PA-C)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:JANE
Last Name:LUBENOW
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:JANE
Other - Last Name:STORK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4261 W. BERINGER DRIVE
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546
Mailing Address - Country:US
Mailing Address - Phone:773-332-2412
Mailing Address - Fax:812-482-3993
Practice Address - Street 1:613 DORBETT ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-2615
Practice Address - Country:US
Practice Address - Phone:812-481-2229
Practice Address - Fax:812-482-3993
Is Sole Proprietor?:No
Enumeration Date:2008-01-24
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.003092363A00000X
IN10001172A363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300015512Medicaid
KY7100561200Medicaid