Provider Demographics
NPI:1679306252
Name:BETCHLEY, BRYANA SHEA (CST/ CSFA)
Entity type:Individual
Prefix:
First Name:BRYANA
Middle Name:SHEA
Last Name:BETCHLEY
Suffix:
Gender:F
Credentials:CST/ CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 W MAIN ST LOT 94
Mailing Address - Street 2:
Mailing Address - City:WHITEHOUSE
Mailing Address - State:TX
Mailing Address - Zip Code:75791-3466
Mailing Address - Country:US
Mailing Address - Phone:903-343-3418
Mailing Address - Fax:
Practice Address - Street 1:800 E DAWSON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2036
Practice Address - Country:US
Practice Address - Phone:903-606-4840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-20
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX175638207X00000X, 246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery