Healthcare Provider Details

I. General information

NPI: 1184249138
Provider Name (Legal Business Name): CAMERON LEWIS BENNETT MPAS, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2020
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 W 400 S
SALT LAKE CITY UT
84101-1135
US

IV. Provider business mailing address

409 W 400 S
SALT LAKE CITY UT
84101-1135
US

V. Phone/Fax

Practice location:
  • Phone: 801-364-0058
  • Fax:
Mailing address:
  • Phone: 801-364-0058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12456910-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12456910-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: