Basic Information
| Provider Information | |||||||||
| NPI: | 1851581573 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHANKU | ||||||||
| FirstName: | BETHANY | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DANSON | ||||||||
| OtherFirstName: | BETHANY | ||||||||
| OtherMiddleName: | R | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 157 REMSEN ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112014321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182601000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 157 REMSEN ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112014321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182601000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2007 | ||||||||
| LastUpdateDate: | 10/25/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA1507 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 0796 | NH | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 015254 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 4158075 | 01 | TN | BC/BS TN - CUMBERLAND BACK PAIN CLINIC, P.C. | OTHER | 4190395 | 01 | TN | BS/BS TN - LEBANON BACK PAIN CLINIC, P.C. | OTHER | 3665093 | 05 | TN | MEDICAID | PA1507 | 01 | TN | STATE LICENSE | OTHER |