Provider Demographics
NPI:1285622589
Name:BENNETT, STEPHEN A (PAC)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:A
Last Name:BENNETT
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1128 NE 2ND ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-6230
Mailing Address - Country:US
Mailing Address - Phone:541-257-2512
Mailing Address - Fax:541-754-2707
Practice Address - Street 1:1128 NE 2ND ST
Practice Address - Street 2:SUITE 201
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-6230
Practice Address - Country:US
Practice Address - Phone:541-257-2512
Practice Address - Fax:541-754-2707
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00868363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR134132Medicaid
P22733Medicare UPIN
R130057Medicare PIN
ORP00441182Medicare PIN
OR130057Medicare ID - Type Unspecified
5377250001Medicare NSC