Provider Demographics
NPI:1598478950
Name:KOENIG, BETHANY MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:MARIE
Last Name:KOENIG
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 1:911 WALLACE DR
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-8971
Mailing Address - Country:US
Mailing Address - Phone:937-216-5882
Mailing Address - Fax:
Practice Address - Street 1:3535 OLENTANGY RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3998
Practice Address - Country:US
Practice Address - Phone:614-566-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-02
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.007952RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant