Provider Demographics
NPI:1376555961
Name:BENNETT, ANGELA J (PA-C)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:J
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:ANGELA
Other - Middle Name:J
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C, MPAS
Mailing Address - Street 1:935 STATE ROUTE 28
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45150-1957
Mailing Address - Country:US
Mailing Address - Phone:513-831-5955
Mailing Address - Fax:
Practice Address - Street 1:935 STATE ROUTE 28
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:OH
Practice Address - Zip Code:45150-1957
Practice Address - Country:US
Practice Address - Phone:513-831-5955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50002465363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPA36592Medicare PIN
OHPA36591Medicare PIN
OHHO04420Medicare PIN
OHPA36953Medicare PIN