Provider Demographics
NPI:1710961156
Name:BENTSON, KENNETH J (PA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:BENTSON
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 1:1230 E MAIN ST
Mailing Address - Street 2:PO BOX 8674
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-5066
Mailing Address - Country:US
Mailing Address - Phone:507-625-1811
Mailing Address - Fax:
Practice Address - Street 1:1575 LOOKOUT DR
Practice Address - Street 2:
Practice Address - City:NORTH MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56003-2503
Practice Address - Country:US
Practice Address - Phone:507-625-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9954363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNQ10315Medicare UPIN
MNQ10315Medicare UPIN