Provider Demographics
NPI:1629177647
Name:BENTLEY, DANIEL A (PA)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:A
Last Name:BENTLEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 COLLIER RD
Mailing Address - Street 2:SUITE 5015
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309
Mailing Address - Country:US
Mailing Address - Phone:404-605-2800
Mailing Address - Fax:
Practice Address - Street 1:1401 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2315
Practice Address - Country:US
Practice Address - Phone:815-391-6102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104555363AS0400X
IL085.004313363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAK297ZMedicare PIN