Provider Demographics
NPI:1417424011
Name:BENNETT, BRYAN KING (PA-C)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:KING
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 1:48542 GAMMON CT UNIT 2
Mailing Address - Street 2:
Mailing Address - City:FORT HOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76544-1804
Mailing Address - Country:US
Mailing Address - Phone:315-222-3564
Mailing Address - Fax:
Practice Address - Street 1:CARL R DARNALL ARMY MEDICAL CENTER, 36065 SANTA FE AVE.
Practice Address - Street 2:
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544
Practice Address - Country:US
Practice Address - Phone:315-222-3564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-01
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant