Provider Demographics
NPI:1043251325
Name:BENECK, JOHN J (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:BENECK
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 1:1177 N ROAD ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-3388
Mailing Address - Country:US
Mailing Address - Phone:252-384-2560
Mailing Address - Fax:252-384-9997
Practice Address - Street 1:1177 N ROAD ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3388
Practice Address - Country:US
Practice Address - Phone:252-384-2560
Practice Address - Fax:252-384-9997
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA-586363A00000X
NC0010-06453363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MES82737Medicare UPIN
MEAP1064Medicare PIN