Provider Demographics
NPI:1689882110
Name:FISHER, BETHANY KATHERINE (PAC)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:KATHERINE
Last Name:FISHER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:K
Other - Last Name:TACY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:115 HERITAGE LN
Mailing Address - Street 2:
Mailing Address - City:MANNINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:26582-6478
Mailing Address - Country:US
Mailing Address - Phone:304-672-2011
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301
Practice Address - Country:US
Practice Address - Phone:304-623-3461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV351363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVST6036771Medicare PIN