Provider Demographics
NPI:1972695534
Name:BENNETT, SUSAN M (RPA-C)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:M
Last Name:BENNETT
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6760 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-5947
Mailing Address - Country:US
Mailing Address - Phone:716-626-0030
Mailing Address - Fax:716-632-5356
Practice Address - Street 1:6760 MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-5947
Practice Address - Country:US
Practice Address - Phone:716-626-0030
Practice Address - Fax:716-632-5356
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006519363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYAA0403Medicare PIN
NYCC3908Medicare PIN
NYCC3908Medicare ID - Type UnspecifiedPROVIDER IDENTIFICATION