Provider Demographics
NPI:1184619876
Name:STACK, BETHANY LYNN (PA)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:LYNN
Last Name:STACK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 ALBERT CREE DR
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4601
Mailing Address - Country:US
Mailing Address - Phone:802-775-2937
Mailing Address - Fax:802-773-0934
Practice Address - Street 1:3 ALBERT CREE DR
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4601
Practice Address - Country:US
Practice Address - Phone:802-775-2937
Practice Address - Fax:802-773-0934
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-19
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055-0030670363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT00059907OtherBCBS
VT00059907OtherBCBS
VTQ18699Medicare UPIN