Provider Demographics
NPI:1306136643
Name:DESIMONE, BETHANY J (ATC)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:J
Last Name:DESIMONE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 112TH AVE NE STE D154
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3727
Mailing Address - Country:US
Mailing Address - Phone:425-643-9778
Mailing Address - Fax:425-643-6448
Practice Address - Street 1:1750 112TH AVE NE STE D154
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3727
Practice Address - Country:US
Practice Address - Phone:425-643-9778
Practice Address - Fax:425-643-6448
Is Sole Proprietor?:No
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAA1 600453572083S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine