Provider Demographics
NPI:1124485941
Name:KNORR, BETHANY (PA-C)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:KNORR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:
Other - Last Name:SOUCY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 229
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02880-0229
Mailing Address - Country:US
Mailing Address - Phone:401-788-8757
Mailing Address - Fax:
Practice Address - Street 1:268 POST RD
Practice Address - Street 2:
Practice Address - City:WESTERLY
Practice Address - State:RI
Practice Address - Zip Code:02891-6600
Practice Address - Country:US
Practice Address - Phone:401-604-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-25
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA00859363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical