Provider Demographics
NPI:1083085948
Name:BENNETT, MICHAEL DOUGLAS (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DOUGLAS
Last Name:BENNETT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:560 S LOOP RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3405
Mailing Address - Country:US
Mailing Address - Phone:859-301-2663
Mailing Address - Fax:859-817-7848
Practice Address - Street 1:2626 ALEXANDRIA PIKE STE 100
Practice Address - Street 2:
Practice Address - City:HIGHLAND HEIGHTS
Practice Address - State:KY
Practice Address - Zip Code:41076-1530
Practice Address - Country:US
Practice Address - Phone:859-301-2663
Practice Address - Fax:859-817-7848
Is Sole Proprietor?:No
Enumeration Date:2015-10-16
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH50.004487363A00000X
KYPA2067363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant