Provider Demographics
NPI:1184173429
Name:BENNETT, MATTHEW EDWARD (PA-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:EDWARD
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 1:2488 E IRLO BRONSON MEMORIAL HWY STE 204
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-4948
Mailing Address - Country:US
Mailing Address - Phone:407-846-6004
Mailing Address - Fax:
Practice Address - Street 1:2488 E IRLO BRONSON MEMORIAL HWY STE 204
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-4948
Practice Address - Country:US
Practice Address - Phone:407-846-6004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-28
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109845363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical