Provider Demographics
NPI:1477938058
Name:BENNETT, ABIGAIL FRERICKS (PA-C)
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:FRERICKS
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ABIGAIL
Other - Middle Name:GRACE
Other - Last Name:FRERICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1885 PLAZA DR
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-2979
Practice Address - Country:US
Practice Address - Phone:952-993-4001
Practice Address - Fax:952-993-4095
Is Sole Proprietor?:No
Enumeration Date:2015-07-24
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2288363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant