Provider Demographics
NPI:1902957301
Name:WILSACK, BETHAN H (PA)
Entity Type:Individual
Prefix:
First Name:BETHAN
Middle Name:H
Last Name:WILSACK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 MALL RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0001
Mailing Address - Country:US
Mailing Address - Phone:781-744-8000
Mailing Address - Fax:781-744-5236
Practice Address - Street 1:67 S BEDFORD ST STE 202E
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01803-5141
Practice Address - Country:US
Practice Address - Phone:781-744-7000
Practice Address - Fax:781-744-5236
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA1025363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAQX2397Medicare PIN
MAS75172Medicare UPIN