Provider Demographics
NPI:1992250096
Name:BENNETT, BROOKE (PA-C)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
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 1:325 MAINE STREET
Mailing Address - Street 2:MSO LIBRARY
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044
Mailing Address - Country:US
Mailing Address - Phone:785-505-2988
Mailing Address - Fax:785-505-5228
Practice Address - Street 1:1130 W 4TH ST STE 3200
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-1346
Practice Address - Country:US
Practice Address - Phone:785-505-5885
Practice Address - Fax:785-505-5302
Is Sole Proprietor?:No
Enumeration Date:2016-08-18
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018033452363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical