MEDICARE: MRS. AMBER D BETHEA 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	363AS0400X	Surgical Physician Assistant	C02148	MD

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00187315	OTHER	MD	R/R MEDICARE PROVIDER #
2	CA8374	OTHER	MD	R/R MEDICARE GROUP #

General Provider Information

NPI Number	:	1578526901
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AMBER D BETHEA PA-C

Provider Business Mailing Address
First Line	:	2900 SAINT MICHAEL DR STE 401
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75503-5211
Country	:	US
Telephone Number	:	903-614-5393
Fax Number	:	214-614-5343

Provider Business Practice Location Address
First Line	:	2604 SAINT MICHAEL DR STE 425
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75503-2378
Country	:	US
Telephone Number	:	903-614-5600
Fax Number	:	903-614-5630

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

Provider Enumeration Date	:	04/07/2006
Last Update Date	:	05/29/2019

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