Basic Information
| Provider Information | |||||||||
| NPI: | 1992193676 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BETHEA | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | ISAAC | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2488 E 81ST ST STE 290 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741374265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9189273226 | ||||||||
| FaxNumber: | 9189273193 | ||||||||
| Practice Location | |||||||||
| Address1: | 1071 W BLUE STARR DR STE 105 | ||||||||
| Address2: | |||||||||
| City: | CLAREMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740172869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183610600 | ||||||||
| FaxNumber: | 9189273201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2015 | ||||||||
| LastUpdateDate: | 02/23/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2431 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 200570050A | 05 | OK | MEDICAID |