Provider Demographics
NPI:1295702371
Name:BERGHOFFER, BETHANY LYNN (PA C)
Entity type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:LYNN
Last Name:BERGHOFFER
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:MS
Other - First Name:BETHANY
Other - Middle Name:LYNN
Other - Last Name:TIPPETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA C
Mailing Address - Street 1:2863 ALT 19
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-1926
Mailing Address - Country:US
Mailing Address - Phone:727-781-5652
Mailing Address - Fax:727-786-5416
Practice Address - Street 1:2863 ALT 19
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683-1926
Practice Address - Country:US
Practice Address - Phone:272-781-5652
Practice Address - Fax:727-786-5416
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001819363AM0700X
FLPA9104980363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
A09299Medicare UPIN
VA013493E14Medicare ID - Type Unspecified