Provider Demographics
NPI:1205277571
Name:BENNINGTON, NEA RAE (PA-C)
Entity type:Individual
Prefix:
First Name:NEA
Middle Name:RAE
Last Name:BENNINGTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NEA
Other - Middle Name:RAE
Other - Last Name:HARKNESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3931 LOUISIANA AVE S
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-5000
Practice Address - Country:US
Practice Address - Phone:952-993-3230
Practice Address - Fax:952-993-1748
Is Sole Proprietor?:No
Enumeration Date:2013-07-15
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11384363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant