Provider Demographics
NPI:1669777009
Name:BENNETT, RICHARD OLIVER (RPA-C)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:OLIVER
Last Name:BENNETT
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1745 UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-7952
Mailing Address - Country:US
Mailing Address - Phone:631-328-5560
Mailing Address - Fax:631-328-5559
Practice Address - Street 1:2 ELLIS CT
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-1473
Practice Address - Country:US
Practice Address - Phone:917-837-8213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-16
Last Update Date:2017-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY23-014569363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical