Provider Demographics
NPI:1679056659
Name:STADLER, BENNETT ROBERT
Entity Type:Individual
Prefix:
First Name:BENNETT
Middle Name:ROBERT
Last Name:STADLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:673 MDG 5955 ZEAMER AVENUE
Mailing Address - Street 2:
Mailing Address - City:JBER
Mailing Address - State:AK
Mailing Address - Zip Code:99506
Mailing Address - Country:US
Mailing Address - Phone:907-580-1571
Mailing Address - Fax:
Practice Address - Street 1:673 MDG 5955 ZEAMER AVENUE
Practice Address - Street 2:
Practice Address - City:JBER
Practice Address - State:AK
Practice Address - Zip Code:99506
Practice Address - Country:US
Practice Address - Phone:907-580-1571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-14
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant