Provider Demographics
NPI:1710127642
Name:LEMMON, BETHANY S (PA-C)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:S
Last Name:LEMMON
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 1:1155 W PARKVIEW ST STE 1G
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-8597
Mailing Address - Country:US
Mailing Address - Phone:417-326-8700
Mailing Address - Fax:417-777-8173
Practice Address - Street 1:1155 W PARKVIEW ST STE 1G
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-8597
Practice Address - Country:US
Practice Address - Phone:417-326-8700
Practice Address - Fax:417-777-8173
Is Sole Proprietor?:No
Enumeration Date:2009-03-05
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MO2009004297363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOPENDINGMedicare PIN