Provider Demographics
NPI:1518955483
Name:BENNETT, BRETT J (MA-PAC)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:J
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MA-PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 E 19TH ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5405
Mailing Address - Country:US
Mailing Address - Phone:918-748-7599
Mailing Address - Fax:918-748-7539
Practice Address - Street 1:1705 E 19TH ST
Practice Address - Street 2:SUITE 302
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5405
Practice Address - Country:US
Practice Address - Phone:918-748-7599
Practice Address - Fax:918-748-7539
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK999363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q10872Medicare UPIN
OK241412903Medicare ID - Type Unspecified