Provider Demographics
NPI:1831189117
Name:BENNETT, REBECCA LYNN (PA-C)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNN
Last Name:BENNETT
Suffix:
Gender:F
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 1:49725 COUNTY 83
Mailing Address - Street 2:
Mailing Address - City:STAPLES
Mailing Address - State:MN
Mailing Address - Zip Code:56479-5280
Mailing Address - Country:US
Mailing Address - Phone:218-894-1515
Mailing Address - Fax:218-894-8767
Practice Address - Street 1:49725 COUNTY 83
Practice Address - Street 2:
Practice Address - City:STAPLES
Practice Address - State:MN
Practice Address - Zip Code:56479-5280
Practice Address - Country:US
Practice Address - Phone:218-894-1515
Practice Address - Fax:218-894-8767
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9463363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNS90775Medicare UPIN