Healthcare Provider Details

I. General information

NPI: 1083554406
Provider Name (Legal Business Name): BETHANY BUSSEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 03/30/2026
Certification Date: 03/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 CROSSINGS BLVD
WARWICK RI
02886-2878
US

IV. Provider business mailing address

10 SHANGRI LA LN
MIDDLETOWN RI
02842-5438
US

V. Phone/Fax

Practice location:
  • Phone: 401-777-7000
  • Fax:
Mailing address:
  • Phone: 630-881-8713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: