Provider Demographics
NPI:1588036396
Name:BENNETT, ANDREW LEON (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:LEON
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5102 HOWARD LN
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-8659
Mailing Address - Country:US
Mailing Address - Phone:208-467-3509
Mailing Address - Fax:
Practice Address - Street 1:5102 HOWARD LN
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-8659
Practice Address - Country:US
Practice Address - Phone:208-467-3509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-21
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00028532207Q00000X
IDM-14113207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine