Provider Demographics
NPI:1609822436
Name:BENNETT, JOAN (PA)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name: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 1:255 W LANCASTER AVE
Mailing Address - Street 2:
Mailing Address - City:PAOLI
Mailing Address - State:PA
Mailing Address - Zip Code:19301-1763
Mailing Address - Country:US
Mailing Address - Phone:610-648-1000
Mailing Address - Fax:
Practice Address - Street 1:255 W LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301-1763
Practice Address - Country:US
Practice Address - Phone:610-648-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002787L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA094946Medicare ID - Type Unspecified
P11083Medicare UPIN