Provider Demographics
NPI:1447891353
Name:RUSSOTTO, BETHANY (PA-C)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:RUSSOTTO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD # PPV05
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3098
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD # PPV05
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3098
Practice Address - Country:US
Practice Address - Phone:714-449-7400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-02
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA208945363A00000X, 363AM0700X
363A00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty