Provider Demographics
NPI:1023316122
Name:PEATTIE, BETHANY (CRNA)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:PEATTIE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13809 RESEARCH BLVD STE 500
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78750-1223
Mailing Address - Country:US
Mailing Address - Phone:919-904-0310
Mailing Address - Fax:
Practice Address - Street 1:100 MCGREGOR ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03102-3730
Practice Address - Country:US
Practice Address - Phone:603-668-3545
Practice Address - Fax:434-517-3021
Is Sole Proprietor?:No
Enumeration Date:2011-03-14
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024169277367500000X
NH0582311-23367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA002469277OtherLICENSE
NH0582311-23Medicaid