Provider Demographics
NPI:1669039525
Name:BENNETT, DUSTIN LANSING (PA-C)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:LANSING
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 1:2655 E DEER SPRINGS WAY APT 3130
Mailing Address - Street 2:
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89086-1479
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15301 WARREN SHINGLE RD
Practice Address - Street 2:
Practice Address - City:BEALE AFB
Practice Address - State:CA
Practice Address - Zip Code:95903-1905
Practice Address - Country:US
Practice Address - Phone:530-435-5362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-24
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1669039525OtherDOD