Provider Demographics
NPI:1093354573
Name:BENTLEY, KEITH
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:BENTLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 E 30TH ST APT 16B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-7381
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1907 BORDER AVE
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90501-3606
Practice Address - Country:US
Practice Address - Phone:844-443-6246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-31
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical