Provider Demographics
NPI:1093469017
Name:BENNETT, JOSHUA (PA-C)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:BENNETT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2232 NW 196TH ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-3636
Mailing Address - Country:US
Mailing Address - Phone:858-245-0998
Mailing Address - Fax:
Practice Address - Street 1:13101 MEMORIAL SPRINGS CT
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-2226
Practice Address - Country:US
Practice Address - Phone:405-438-3004
Practice Address - Fax:405-438-3001
Is Sole Proprietor?:No
Enumeration Date:2022-02-08
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4748363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical