Healthcare Provider Details

I. General information

NPI: 1871859223
Provider Name (Legal Business Name): MARK KENNETH BENNETT PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 09/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4403 HARRISON BLVD SUITE 1815
OGDEN UT
84403-3339
US

IV. Provider business mailing address

PO BOX 5546
DENVER CO
80217-5546
US

V. Phone/Fax

Practice location:
  • Phone: 801-387-6520
  • Fax: 801-387-6525
Mailing address:
  • Phone: 801-475-3481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number8134401-8906
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number8134401-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: