Provider Demographics
NPI:1215196134
Name:BENTLEY, DANIEL J (PA)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:J
Last Name:BENTLEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2620 EAST BARNETT RD
Mailing Address - Street 2:SUITE H
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8383
Mailing Address - Country:US
Mailing Address - Phone:541-789-4281
Mailing Address - Fax:541-789-5538
Practice Address - Street 1:2825 EAST BARNETT RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8332
Practice Address - Country:US
Practice Address - Phone:541-789-6460
Practice Address - Fax:541-789-5538
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORPA161231363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health