Provider Demographics
NPI:1114903432
Name:BENNETT, DAVID G (PA-C)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:G
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 1:100 BREWSTER BLVD
Mailing Address - Street 2:
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28547-2575
Mailing Address - Country:US
Mailing Address - Phone:910-450-4799
Mailing Address - Fax:
Practice Address - Street 1:100 BREWSTER BLVD
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547-2575
Practice Address - Country:US
Practice Address - Phone:910-450-4799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00159363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q50738Medicare UPIN