Provider Demographics
NPI:1750307690
Name:BENNETT-GAYLE, FLETCHER K (PA-C)
Entity Type:Individual
Prefix:
First Name:FLETCHER
Middle Name:K
Last Name:BENNETT-GAYLE
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 1:3742 WINTERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-9238
Mailing Address - Country:US
Mailing Address - Phone:804-330-3335
Mailing Address - Fax:804-330-9205
Practice Address - Street 1:3742 WINTERFIELD RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-9238
Practice Address - Country:US
Practice Address - Phone:804-330-3335
Practice Address - Fax:804-330-9205
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005805363A00000X
NJMP634363A00000X
VA0110001514363A00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA001438V21Medicare PIN
VA001832V20Medicare PIN
VA018412V21Medicare PIN
P39769Medicare UPIN
VAVAA103006Medicare PIN
VA001435V01Medicare PIN
VA015603V68Medicare PIN