Provider Demographics
NPI:1376955971
Name:BENNETT, MATTHEW RAY (PA-C)
Entity Type:Individual
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First Name:MATTHEW
Middle Name:RAY
Last Name:BENNETT
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:4200 DAHLBERG DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4840
Mailing Address - Country:US
Mailing Address - Phone:952-512-5600
Mailing Address - Fax:952-512-5651
Practice Address - Street 1:560 S MAPLE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1733
Practice Address - Country:US
Practice Address - Phone:952-442-2163
Practice Address - Fax:952-442-5903
Is Sole Proprietor?:No
Enumeration Date:2014-05-30
Last Update Date:2015-01-09
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Provider Licenses
StateLicense IDTaxonomies
MN2193363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical