MEDICARE: LAURA C BENNETT PA

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	363A00000X	Physician Assistant	103420	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1285682310	OTHER	NC	WSCA GRP NPI #

General Provider Information

NPI Number	:	1487633483
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA C BENNETT PA

Provider Business Mailing Address
First Line	:	2000 FRONTIS PLAZA BLVD STE 200
Second Line	:	(ATTN) FORSYTH MEDICAL GROUP
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-5616
Country	:	US
Telephone Number	:	336-277-2435
Fax Number	:	336-277-9275

Provider Business Practice Location Address
First Line	:	186 KIMEL PARK DR
Second Line	:	ATTN: WINSTON-SALEM CARDIOLOGY
City	:	WINSTON-SALEM
State	:	NC
Zip	:	27103-6946
Country	:	US
Telephone Number	:	336-277-2000
Fax Number	:	336-277-2050

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

Provider Enumeration Date	:	01/10/2006
Last Update Date	:	09/13/2007

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Directions to “ LAURA C BENNETT PA” Practice Location

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