Provider Demographics
NPI:1679390496
Name:BENNETT, MICHAEL ANTHONY (NP)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:BENNETT
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 HOLLY KNOLL DR
Mailing Address - Street 2:
Mailing Address - City:CHURCHVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18966-1439
Mailing Address - Country:US
Mailing Address - Phone:215-828-3777
Mailing Address - Fax:
Practice Address - Street 1:517 HOLLY KNOLL DR
Practice Address - Street 2:
Practice Address - City:CHURCHVILLE
Practice Address - State:PA
Practice Address - Zip Code:18966-1439
Practice Address - Country:US
Practice Address - Phone:215-828-3777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-23
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP030521363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology