Basic Information
| Provider Information | |||||||||
| NPI: | 1215331566 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ABDE | ||||||||
| FirstName: | BETHANY | ||||||||
| MiddleName: | JANE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | AGNP - BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PEREIRA | ||||||||
| OtherFirstName: | BETHANY | ||||||||
| OtherMiddleName: | JANE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | AGNP - BC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 200 MILL RD | ||||||||
| Address2: | SUITE 180 | ||||||||
| City: | FAIRHAVEN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027195252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089732000 | ||||||||
| FaxNumber: | 5089732001 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 ROSEBROOK WAY | ||||||||
| Address2: | |||||||||
| City: | WAREHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 025711138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5082734900 | ||||||||
| FaxNumber: | 5082734901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2014 | ||||||||
| LastUpdateDate: | 04/20/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | RN259875 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 110101067A | 05 | MA | MEDICAID |