Provider Demographics
NPI:1871043794
Name:WACKER, BETHANY (RRT)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:WACKER
Suffix:
Gender:F
Credentials:RRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 BROOKHURST ST APT 13
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-5446
Mailing Address - Country:US
Mailing Address - Phone:541-220-8135
Mailing Address - Fax:
Practice Address - Street 1:2000 BROOKHURST ST APT 13
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-5446
Practice Address - Country:US
Practice Address - Phone:541-220-8135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRTP047707227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered