Provider Demographics
NPI:1821461435
Name:BENGEL, NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BENGEL
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 1:115 N EDGMONT ST
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-3013
Mailing Address - Country:US
Mailing Address - Phone:302-530-8813
Mailing Address - Fax:
Practice Address - Street 1:100 E LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:WYNNEWOOD
Practice Address - State:PA
Practice Address - Zip Code:19096-3450
Practice Address - Country:US
Practice Address - Phone:484-476-2826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-04
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0001032363A00000X
PAMA057847363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant