Healthcare Provider Details

I. General information

NPI: 1093469017
Provider Name (Legal Business Name): JOSHUA BENNETT PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2022
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 CRAVEN ST BLDG 3300
SAN DIEGO CA
92136-2226
US

IV. Provider business mailing address

2232 NW 196TH ST
EDMOND OK
73012-3636
US

V. Phone/Fax

Practice location:
  • Phone: 619-881-9202
  • Fax:
Mailing address:
  • Phone: 858-245-0998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4748
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number4748
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA64095
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: