Provider Demographics
NPI:1578526901
Name:BETHEA, AMBER D (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:D
Last Name:BETHEA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 SAINT MICHAEL DR STE 401
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-5211
Mailing Address - Country:US
Mailing Address - Phone:903-614-5393
Mailing Address - Fax:214-614-5343
Practice Address - Street 1:2604 SAINT MICHAEL DR STE 425
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2378
Practice Address - Country:US
Practice Address - Phone:903-614-5600
Practice Address - Fax:903-614-5630
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC02148363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP00187315OtherR/R MEDICARE PROVIDER #
MDCA8374OtherR/R MEDICARE GROUP #
MDP00187315OtherR/R MEDICARE PROVIDER #
MDS567G600Medicare PIN