1023316122 NPI number — BETHANY PEATTIE CRNA

Table of content: BETHANY PEATTIE CRNA (NPI 1023316122)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023316122 NPI number — BETHANY PEATTIE CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEATTIE
Provider First Name:
BETHANY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023316122
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/18/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13809 RESEARCH BLVD STE 500
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78750-1223
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-904-0310
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 MCGREGOR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANCHESTER
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03102-3730
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-668-3545
Provider Business Practice Location Address Fax Number:
434-517-3021
Provider Enumeration Date:
03/14/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  0024169277 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 0582311-23 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 002469277 . This is a "LICENSE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 0582311-23 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110067200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".