Provider Demographics
NPI:1508900218
Name:BENTLEY, MICHELLE A (PA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:A
Last Name:BENTLEY
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 1:434 POTTER BLVD
Mailing Address - Street 2:
Mailing Address - City:BRIGHTWATERS
Mailing Address - State:NY
Mailing Address - Zip Code:11718-1611
Mailing Address - Country:US
Mailing Address - Phone:631-968-1084
Mailing Address - Fax:
Practice Address - Street 1:101 HOSPITAL RD
Practice Address - Street 2:BROOKHAVEN MEMORIAL HOSPITAL
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4870
Practice Address - Country:US
Practice Address - Phone:631-687-4164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009047363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP87234Medicare UPIN