Provider Demographics
NPI:1417531765
Name:BENTLEY, AUSTIN LOUIS (PA)
Entity Type:Individual
Prefix:MR
First Name:AUSTIN
Middle Name:LOUIS
Last Name:BENTLEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2612 PEBBLEBROOK TERRACE CT
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-3970
Mailing Address - Country:US
Mailing Address - Phone:301-706-1894
Mailing Address - Fax:
Practice Address - Street 1:701 CHARLES ST
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-5930
Practice Address - Country:US
Practice Address - Phone:240-686-2300
Practice Address - Fax:240-686-2330
Is Sole Proprietor?:No
Enumeration Date:2021-05-11
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDC08130363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant