Basic Information
| Provider Information | |||||||||
| NPI: | 1386637155 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 806 JEFFERSON TER | ||||||||
| Address2: | |||||||||
| City: | NEW IBERIA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705605727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3373654945 | ||||||||
| FaxNumber: | 3373766860 | ||||||||
| Practice Location | |||||||||
| Address1: | 567 WALKER ST | ||||||||
| Address2: | |||||||||
| City: | MERRYVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706533040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3378251728 | ||||||||
| FaxNumber: | 3378251229 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2005 | ||||||||
| LastUpdateDate: | 10/17/2019 | ||||||||
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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 | 363LF0000X | AP04254 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1477095 | 05 | LA | MEDICAID |