Provider Demographics
NPI:1619374808
Name:PAVON, BETHANY CAROL (FNP)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:CAROL
Last Name:PAVON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 W KING ST STE M
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-2100
Mailing Address - Country:US
Mailing Address - Phone:989-729-4100
Mailing Address - Fax:989-729-4066
Practice Address - Street 1:802 W KING ST STE M
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-2100
Practice Address - Country:US
Practice Address - Phone:989-729-4100
Practice Address - Fax:989-729-4066
Is Sole Proprietor?:No
Enumeration Date:2014-12-03
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704266187363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1619374808Medicaid
MI1619374808Medicaid