Provider Demographics
NPI:1619472792
Name:MARTIN, BETHANY ALICE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:BETHANY
Middle Name:ALICE
Last Name:MARTIN
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 1:50 GREEN PASTURES LN
Mailing Address - Street 2:
Mailing Address - City:MIFFLIN
Mailing Address - State:PA
Mailing Address - Zip Code:17058-7046
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 BERNVILLE RD
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19605
Practice Address - Country:US
Practice Address - Phone:610-378-2423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-29
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA059919363A00000X
PAOA004535363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty