Provider Demographics
NPI:1619636891
Name:GULVEZAN, BETHANY FORSYTHE (AA)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:FORSYTHE
Last Name:GULVEZAN
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 N 87TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3586
Mailing Address - Country:US
Mailing Address - Phone:414-805-9500
Mailing Address - Fax:414-805-9501
Practice Address - Street 1:840 N 87TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3586
Practice Address - Country:US
Practice Address - Phone:414-805-9500
Practice Address - Fax:414-805-9501
Is Sole Proprietor?:No
Enumeration Date:2021-12-15
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI510367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant