Healthcare Provider Details

I. General information

NPI: 1285622589
Provider Name (Legal Business Name): STEPHEN A BENNETT PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 06/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1128 NE 2ND ST SUITE 201
CORVALLIS OR
97330-6230
US

IV. Provider business mailing address

1128 NE 2ND ST SUITE 201
CORVALLIS OR
97330-6230
US

V. Phone/Fax

Practice location:
  • Phone: 541-257-2512
  • Fax: 541-754-2707
Mailing address:
  • Phone: 541-257-2512
  • Fax: 541-754-2707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00868
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: