MEDICARE: MRS. CRISTA MARIE BENNETT PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	OA000896	PA
2	363A00000X	Physician Assistant	MA053375	PA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	341440FFU	OTHER	PA	MEDICARE PTAN

General Provider Information

NPI Number	:	1053315689
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CRISTA MARIE BENNETT PA-C

Provider Business Mailing Address
First Line	:	100 HOSPITAL AVE
Second Line	:
City	:	DU BOIS
State	:	PA
Zip	:	15801-1440
Country	:	US
Telephone Number	:	814-375-6549
Fax Number	:	814-372-2864

Provider Business Practice Location Address
First Line	:	1100 MILLION DOLLAR HWY
Second Line	:
City	:	SAINT MARYS
State	:	PA
Zip	:	15857-2728
Country	:	US
Telephone Number	:	814-781-6758
Fax Number	:	814-781-3317

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2005
Last Update Date	:	12/10/2020

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