MEDICARE: JOSHUA BENNETT PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	4748	OK
2	363A00000X	Physician Assistant	4748	OK
3	363AM0700X	Medical Physician Assistant	PA64095	CA

General Provider Information

NPI Number	:	1093469017
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSHUA BENNETT PA-C

Provider Business Mailing Address
First Line	:	2232 NW 196TH ST
Second Line	:
City	:	EDMOND
State	:	OK
Zip	:	73012-3636
Country	:	US
Telephone Number	:	858-245-0998
Fax Number	:

Provider Business Practice Location Address
First Line	:	2450 CRAVEN ST BLDG 3300
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92136-2226
Country	:	US
Telephone Number	:	619-881-9202
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/08/2022
Last Update Date	:	03/03/2025

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Directions to “ JOSHUA BENNETT PA-C” Practice Location

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