Provider Demographics
NPI:1851581573
Name:SHANKU, BETHANY R (PA-C)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:R
Last Name:SHANKU
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:R
Other - Last Name:DANSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:157 REMSEN ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-4321
Mailing Address - Country:US
Mailing Address - Phone:718-260-1000
Mailing Address - Fax:
Practice Address - Street 1:157 REMSEN ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-4321
Practice Address - Country:US
Practice Address - Phone:718-260-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA1507363AM0700X
NH0796363A00000X
NY015254363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4158075OtherBC/BS TN - CUMBERLAND BACK PAIN CLINIC, P.C.
TN4190395OtherBS/BS TN - LEBANON BACK PAIN CLINIC, P.C.
TN3665093Medicaid
TNPA1507OtherSTATE LICENSE
TN3665093Medicare PIN