Provider Demographics
NPI:1346595238
Name:BUIE, BETHANY LISI (PA)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:LISI
Last Name:BUIE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:ANN
Other - Last Name:LISI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:336-716-3636
Mailing Address - Fax:336-713-7314
Practice Address - Street 1:MEDICAL CENTER BVLD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-1247
Practice Address - Country:US
Practice Address - Phone:336-716-3636
Practice Address - Fax:336-713-7314
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03594207Y00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8102584Medicaid
NCNC7360EMedicare PIN