Healthcare Provider Details

I. General information

NPI: 1801996061
Provider Name (Legal Business Name): DEBORAH L BENNING PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 10/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 N WASHINGTON ST
COUNCIL GROVE KS
66846-1422
US

IV. Provider business mailing address

600 N WASHINGTON ST
COUNCIL GROVE KS
66846-1422
US

V. Phone/Fax

Practice location:
  • Phone: 620-767-5126
  • Fax: 620-767-6910
Mailing address:
  • Phone: 620-767-5126
  • Fax: 620-767-6910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberT-00882
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: