Basic Information
| Provider Information | |||||||||
| NPI: | 1487764833 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACKETER | ||||||||
| FirstName: | BETHANY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2050 S BLOSSER RD | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934587310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8053618030 | ||||||||
| FaxNumber: | 8053618097 | ||||||||
| Practice Location | |||||||||
| Address1: | 1330 LAS TABLAS RD | ||||||||
| Address2: | |||||||||
| City: | TEMPLETON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934659758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055426700 | ||||||||
| FaxNumber: | 8055426791 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 06/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A69805 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A698050 | 05 | CA | MEDICAID |