Provider Demographics
NPI:1265752794
Name:KASSOUF, BETHANY HUNT (PA-C)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:HUNT
Last Name:KASSOUF
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:PO BOX 602658
Mailing Address - Street 2:WAKE FOREST UNIVERSITY HEALTH SCIENCES
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2658
Mailing Address - Country:US
Mailing Address - Phone:336-716-2011
Mailing Address - Fax:
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:WAKE FOREST UNIVERSITY HEALTH SCIENCES
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-2011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-07
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-02330363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCF889AMedicare PIN
NC2762342Medicare PIN