Basic Information
Provider Information | |||||||||
NPI: | 1053315689 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BENNETT | ||||||||
FirstName: | CRISTA | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | VOTANO | ||||||||
OtherFirstName: | CRISTA | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 100 HOSPITAL AVE | ||||||||
Address2: |   | ||||||||
City: | DU BOIS | ||||||||
State: | PA | ||||||||
PostalCode: | 158011440 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8143756549 | ||||||||
FaxNumber: | 8143722864 | ||||||||
Practice Location | |||||||||
Address1: | 1100 MILLION DOLLAR HWY | ||||||||
Address2: |   | ||||||||
City: | SAINT MARYS | ||||||||
State: | PA | ||||||||
PostalCode: | 158572728 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8147816758 | ||||||||
FaxNumber: | 8147813317 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/10/2005 | ||||||||
LastUpdateDate: | 12/10/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/10/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | OA000896 | PA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | MA053375 | PA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 341440FFU | 01 | PA | MEDICARE PTAN | OTHER |