Provider Demographics
NPI:1790457919
Name:FORD, BETHANY ERIN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:ERIN
Last Name:FORD
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 1:6801 JEFFERSON ST NE STE 350
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4361
Mailing Address - Country:US
Mailing Address - Phone:505-847-4100
Mailing Address - Fax:
Practice Address - Street 1:6801 JEFFERSON ST NE STE 350
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4361
Practice Address - Country:US
Practice Address - Phone:505-847-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-05
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2023-0227363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant