Provider Demographics
NPI:1871859223
Name:BENNETT, MARK KENNETH (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:KENNETH
Last Name:BENNETT
Suffix:
Gender:M
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:PO BOX 5546
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-5546
Mailing Address - Country:US
Mailing Address - Phone:801-475-3481
Mailing Address - Fax:
Practice Address - Street 1:4403 HARRISON BLVD
Practice Address - Street 2:SUITE 1815
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3339
Practice Address - Country:US
Practice Address - Phone:801-387-6520
Practice Address - Fax:801-387-6525
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8134401-8906363AM0700X
UT8134401-1206363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical