Provider Demographics
NPI:1710257365
Name:BENTLAGE, ERIC
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:BENTLAGE
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 1:170 BAYOU ST
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-9101
Mailing Address - Country:US
Mailing Address - Phone:248-515-0647
Mailing Address - Fax:
Practice Address - Street 1:580 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2705
Practice Address - Country:US
Practice Address - Phone:906-228-9440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704263932367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered