Healthcare Provider Details

I. General information

NPI: 1487633483
Provider Name (Legal Business Name): LAURA C BENNETT PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 09/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

186 KIMEL PARK DR ATTN: WINSTON-SALEM CARDIOLOGY
WINSTON-SALEM NC
27103-6946
US

IV. Provider business mailing address

2000 FRONTIS PLAZA BLVD STE 200 (ATTN) FORSYTH MEDICAL GROUP
WINSTON SALEM NC
27103-5616
US

V. Phone/Fax

Practice location:
  • Phone: 336-277-2000
  • Fax: 336-277-2050
Mailing address:
  • Phone: 336-277-2435
  • Fax: 336-277-9275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number103420
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: