Provider Demographics
NPI:1700815016
Name:BETHA, TERI (CRNA)
Entity Type:Individual
Prefix:MS
First Name:TERI
Middle Name:
Last Name:BETHA
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 1:555 S TELSHOR BLVD STE 100B
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-3644
Mailing Address - Country:US
Mailing Address - Phone:216-225-7989
Mailing Address - Fax:
Practice Address - Street 1:4311 E LOHMAN AVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8255
Practice Address - Country:US
Practice Address - Phone:575-556-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0737799367500000X
NM58242367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2643858Medicaid
OH8236351Medicare ID - Type Unspecified
OH8236352Medicare ID - Type Unspecified
OH2643858Medicaid