Provider Demographics
NPI:1285691998
Name:SOUTHERN, BETSY W (PA-C)
Entity type:Individual
Prefix:MRS
First Name:BETSY
Middle Name:W
Last Name:SOUTHERN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 KIMEL PARK DR
Mailing Address - Street 2:330
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6984
Mailing Address - Country:US
Mailing Address - Phone:336-765-6181
Mailing Address - Fax:336-765-8492
Practice Address - Street 1:145 KIMEL PARK DR
Practice Address - Street 2:330
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6984
Practice Address - Country:US
Practice Address - Phone:336-765-6181
Practice Address - Fax:336-765-8492
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00149363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q64080Medicare UPIN
2765620Medicare ID - Type Unspecified