Provider Demographics
NPI:1659789253
Name:BENNETT, DANA (PA)
Entity Type:Individual
Prefix:MISS
First Name:DANA
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 1:1 LAUTERBUR DRIVE
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-2231
Mailing Address - Country:US
Mailing Address - Phone:631-444-4392
Mailing Address - Fax:
Practice Address - Street 1:1 LAUTERBUR DRIVE
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-2231
Practice Address - Country:US
Practice Address - Phone:631-444-4392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-27
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030532207P00000X, 207X00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery