MEDICARE: MRS. BETSY W SOUTHERN PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	0010-00149	NC

General Provider Information

NPI Number	:	1285691998
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BETSY W SOUTHERN PA-C

Provider Business Mailing Address
First Line	:	145 KIMEL PARK DR
Second Line	:	330
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-6984
Country	:	US
Telephone Number	:	336-765-6181
Fax Number	:	336-765-8492

Provider Business Practice Location Address
First Line	:	145 KIMEL PARK DR
Second Line	:	330
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-6984
Country	:	US
Telephone Number	:	336-765-6181
Fax Number	:	336-765-8492

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/27/2006
Last Update Date	:	03/16/2016

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