Basic Information
| Provider Information | |||||||||
| NPI: | 1245996271 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BETHKE | ||||||||
| FirstName: | JOSHUA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 NE MOTHER JOSEPH PL | ||||||||
| Address2: | STE 210 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986643295 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602546161 | ||||||||
| FaxNumber: | 3604461146 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 W POPLAR STREET | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098973320 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2021 | ||||||||
| LastUpdateDate: | 05/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | AP61226261 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.