Provider Demographics
NPI:1124292578
Name:SOBERAY BETTS, GRETCHEN (DO)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:
Last Name:SOBERAY BETTS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5502 W BROADWAY AVE
Mailing Address - Street 2:NORTHWEST FAMILY PHYSICIANS
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55428-3508
Mailing Address - Country:US
Mailing Address - Phone:763-504-6500
Mailing Address - Fax:
Practice Address - Street 1:5502 W BROADWAY AVE
Practice Address - Street 2:NORTHWEST FAMILY PHYSICIANS
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55428-3508
Practice Address - Country:US
Practice Address - Phone:763-504-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP653207Q00000X
MO2019031609207Q00000X
MI4301119382207Q00000X
IADO-05412207Q00000X
NE2020207Q00000X
SD11518207Q00000X
MED02923207Q00000X
CODR.0062516207Q00000X
NY299885207Q00000X
MN51283207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine