Provider Demographics
NPI:1215331566
Name:ABDE, BETHANY JANE (AGNP - BC)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:JANE
Last Name:ABDE
Suffix:
Gender:F
Credentials:AGNP - BC
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:JANE
Other - Last Name:PEREIRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AGNP - BC
Mailing Address - Street 1:200 MILL RD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-5252
Mailing Address - Country:US
Mailing Address - Phone:508-973-2000
Mailing Address - Fax:508-973-2001
Practice Address - Street 1:100 ROSEBROOK WAY
Practice Address - Street 2:
Practice Address - City:WAREHAM
Practice Address - State:MA
Practice Address - Zip Code:02571-1138
Practice Address - Country:US
Practice Address - Phone:508-273-4900
Practice Address - Fax:508-273-4901
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-15
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN259875363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110101067AMedicaid
MA110101067AMedicaid