Provider Demographics
NPI:1598837270
Name:BETHUNE, DIEDRA (APRN)
Entity Type:Individual
Prefix:
First Name:DIEDRA
Middle Name:
Last Name:BETHUNE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MS
Other - First Name:DIEDRA
Other - Middle Name:BETHUNE
Other - Last Name:HOYT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2525 4TH AVENUE NORTH
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59101
Mailing Address - Country:US
Mailing Address - Phone:406-248-3637
Mailing Address - Fax:406-254-9330
Practice Address - Street 1:219 EAST MAIN ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802
Practice Address - Country:US
Practice Address - Phone:406-728-5490
Practice Address - Fax:406-728-5497
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRN11641363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT433449Medicaid
37116OtherBCBS
MT433449Medicaid
MT80718Medicare ID - Type Unspecified