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General NPI Number Information
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NPI Number | 1669777009
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Entity Type | Individual
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Provider Name | RICHARD OLIVER BENNETT RPA-C
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Gender | Male
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Dates
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Enumeration Date | 01/16/2011
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Last Update Date | 05/24/2017
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Provider Practice Location Address
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Address Line | 2 ELLIS CT
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City | CORAM
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State | NY
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Zip | 11727-1473
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Country | US
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Telephone | 917-837-8213
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Fax |
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Provider Business Mailing Address
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Address Line | 1745 UNION BLVD
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City | BAY SHORE
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State | NY
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Zip | 11706-7952
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Country | US
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Telephone | 631-328-5560
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Fax | 631-328-5559
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 23-014569
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License Number State | NY
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