Provider Demographics
NPI:1164447165
Name:WAXMAN, BENJAMIN J (PA-C)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:J
Last Name:WAXMAN
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 1:3001 METRO DR
Mailing Address - Street 2:SUITE 330
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4506
Mailing Address - Country:US
Mailing Address - Phone:952-814-6600
Mailing Address - Fax:
Practice Address - Street 1:2800 CHICAGO AVE
Practice Address - Street 2:SUITE 401
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1318
Practice Address - Country:US
Practice Address - Phone:952-814-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9763363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNS62140Medicare UPIN