Provider Demographics
NPI:1811324320
Name:BENTUM, ERNEST (NP)
Entity type:Individual
Prefix:
First Name:ERNEST
Middle Name:
Last Name:BENTUM
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1532 SAN BERNARDINO AVE
Mailing Address - Street 2:STE A2
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-3559
Mailing Address - Country:US
Mailing Address - Phone:909-981-5882
Mailing Address - Fax:
Practice Address - Street 1:1532 SAN BERNARDINO AVE
Practice Address - Street 2:STE A2
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3559
Practice Address - Country:US
Practice Address - Phone:909-981-5882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-28
Last Update Date:2020-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23495363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily