Provider Demographics
NPI:1053315689
Name:BENNETT, CRISTA MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CRISTA
Middle Name:MARIE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:CRISTA
Other - Middle Name:MARIE
Other - Last Name:VOTANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:100 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1440
Mailing Address - Country:US
Mailing Address - Phone:814-375-6549
Mailing Address - Fax:814-372-2864
Practice Address - Street 1:1100 MILLION DOLLAR HWY
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:PA
Practice Address - Zip Code:15857-2728
Practice Address - Country:US
Practice Address - Phone:814-781-6758
Practice Address - Fax:814-781-3317
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA000896363AM0700X
PAMA053375363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA341440FFUOtherMEDICARE PTAN
073754Medicare ID - Type Unspecified
PAOA000896OtherSTATE LICENSURE