Provider Demographics
NPI:1104933241
Name:BATHURST, DEVON ADAIR (PA-C)
Entity type:Individual
Prefix:MRS
First Name:DEVON
Middle Name:ADAIR
Last Name:BATHURST
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DEVON
Other - Middle Name:ADAIR
Other - Last Name:COELLNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:119 OAKFIELD DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5779
Mailing Address - Country:US
Mailing Address - Phone:813-681-5551
Mailing Address - Fax:
Practice Address - Street 1:BRANDON REGIONAL HOSPITAL
Practice Address - Street 2:119 OAKFIELD DR.
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511
Practice Address - Country:US
Practice Address - Phone:813-681-5551
Practice Address - Fax:757-686-0541
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001432363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA022348E07Medicare PIN