Provider Demographics
NPI:1720003189
Name:BENTLEY, LYNDA DIANNE (PA)
Entity Type:Individual
Prefix:
First Name:LYNDA
Middle Name:DIANNE
Last Name:BENTLEY
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:PO BOX 490
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:OK
Mailing Address - Zip Code:73628-0490
Mailing Address - Country:US
Mailing Address - Phone:580-497-3333
Mailing Address - Fax:580-497-2778
Practice Address - Street 1:101 FK BUSTER AVE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:OK
Practice Address - Zip Code:73628
Practice Address - Country:US
Practice Address - Phone:580-497-3333
Practice Address - Fax:580-497-2778
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA912363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100161610AMedicaid
S70698Medicare UPIN
OKPA912Medicare ID - Type Unspecified