Provider Demographics
NPI:1023010717
Name:BENNETT, LAURA (PA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BENNETT
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:PO BOX 6369
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59604-6369
Mailing Address - Country:US
Mailing Address - Phone:406-447-2823
Mailing Address - Fax:406-447-2825
Practice Address - Street 1:3330 PTARMIGAN LN
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59602-0521
Practice Address - Country:US
Practice Address - Phone:406-457-4180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT267363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTP28651Medicare UPIN