Provider Demographics
NPI:1427111491
Name:BENNETT, DOUGLAS PORTER (PA-C)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:PORTER
Last Name:BENNETT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 HOSPITAL DR
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:YORK
Mailing Address - State:ME
Mailing Address - Zip Code:03909-1011
Mailing Address - Country:US
Mailing Address - Phone:207-351-2478
Mailing Address - Fax:207-351-2153
Practice Address - Street 1:16 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:ME
Practice Address - Zip Code:03909
Practice Address - Country:US
Practice Address - Phone:207-363-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA-625363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AP2029Medicare ID - Type UnspecifiedB
Q01498Medicare UPIN
MEAP202901Medicare PIN