Basic Information
| Provider Information | |||||||||
| NPI: | 1740228501 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 TAMPA GENERAL CIR OFC | ||||||||
| Address2: | SUITE A327 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336063571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138444434 | ||||||||
| FaxNumber: | 8138444972 | ||||||||
| Practice Location | |||||||||
| Address1: | 10301 GATEWAY BLVD W | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799257701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155959000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 07/19/2016 | ||||||||
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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 | 367500000X | ARNP9181218 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 2946 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | AP112158 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | G3173M | 01 | FL | MEDICARE | OTHER | G3173 | 01 | FL | BCBS FLORIDA | OTHER | 305016500 | 05 | FL | MEDICAID |