Provider Demographics
NPI:1700855087
Name:BENNETT, SALLY S (PA-C)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:S
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-643-2400
Mailing Address - Fax:515-643-4766
Practice Address - Street 1:5900 E UNIVERSITY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PLEASANT HILL
Practice Address - State:IA
Practice Address - Zip Code:50327-8466
Practice Address - Country:US
Practice Address - Phone:515-643-2400
Practice Address - Fax:515-643-4766
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001630363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAQ21887Medicare UPIN
IAI15091Medicare ID - Type Unspecified