Provider Demographics
NPI:1194482067
Name:BENTLEY, PAUL W
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:W
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 1:1365 E PARKS HWY
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-8298
Mailing Address - Country:US
Mailing Address - Phone:907-375-6445
Mailing Address - Fax:
Practice Address - Street 1:1365 E PARKS HWY
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8298
Practice Address - Country:US
Practice Address - Phone:907-375-6445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-26
Last Update Date:2021-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker