Provider Demographics
NPI:1528368354
Name:SNOW, BETHANY S (PA)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:S
Last Name:SNOW
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 BREWSTER STREET
Mailing Address - Street 2:WOOD BLDG #516
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-4400
Mailing Address - Country:US
Mailing Address - Phone:401-729-3481
Mailing Address - Fax:401-729-3721
Practice Address - Street 1:111 BREWSTER STREET
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-4400
Practice Address - Country:US
Practice Address - Phone:401-729-2419
Practice Address - Fax:401-729-2517
Is Sole Proprietor?:No
Enumeration Date:2010-10-27
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4077363A00000X
RIPA00586363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIBS84271Medicaid
RI001937701OtherMEDICARE PTAN