Provider Demographics
NPI:1366061079
Name:BENNETT, ERIN LEIGH (PA-S2)
Entity type:Individual
Prefix:MRS
First Name:ERIN
Middle Name:LEIGH
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PA-S2
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 LIND AVE SW
Mailing Address - Street 2:SUITE 100 ATTN CREDENTIALING
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-4970
Mailing Address - Country:US
Mailing Address - Phone:425-690-2715
Mailing Address - Fax:
Practice Address - Street 1:17722 TALBOT RD S
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5744
Practice Address - Country:US
Practice Address - Phone:425-690-3479
Practice Address - Fax:425-690-9479
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-13
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61090769363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2165521Medicaid