Provider Demographics
NPI:1497728026
Name:GAYLE-BENNETT, ANDREA (PA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:GAYLE-BENNETT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 SAVOY ST
Mailing Address - Street 2:FLOOR
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01904-2119
Mailing Address - Country:US
Mailing Address - Phone:781-581-2232
Mailing Address - Fax:
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:CHILDREN'S HOSPITAL
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-355-7953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA480363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAP1560Medicare ID - Type Unspecified
MAP42577Medicare UPIN