Basic Information
Provider Information | |||||||||
NPI: | 1871632109 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BETIT | ||||||||
FirstName: | ALAN | ||||||||
MiddleName: | THEODULE | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | ANP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 711 TROY SCHENECTADY RD STE 203 | ||||||||
Address2: |   | ||||||||
City: | LATHAM | ||||||||
State: | NY | ||||||||
PostalCode: | 121102461 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5187823700 | ||||||||
FaxNumber: | 5187823799 | ||||||||
Practice Location | |||||||||
Address1: | 711 TROY SCHENECTADY RD STE 104 | ||||||||
Address2: |   | ||||||||
City: | LATHAM | ||||||||
State: | NY | ||||||||
PostalCode: | 121102454 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5187833110 | ||||||||
FaxNumber: | 5182209506 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/05/2007 | ||||||||
LastUpdateDate: | 01/14/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 304580 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
ID | Type | State | Issuer | Description | 02884953 | 05 | NY |   | MEDICAID |