Basic Information
| Provider Information | |||||||||
| NPI: | 1376955971 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | RAY | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4200 DAHLBERG DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525125600 | ||||||||
| FaxNumber: | 9525125651 | ||||||||
| Practice Location | |||||||||
| Address1: | 560 S MAPLE ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553871733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524422163 | ||||||||
| FaxNumber: | 9524425903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2014 | ||||||||
| LastUpdateDate: | 01/09/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 2193 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.