Provider Demographics
NPI:1174652143
Name:PROHASKA, BENJAMIN DALE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:DALE
Last Name:PROHASKA
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5444 RENO CORPORATE DR
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-2250
Mailing Address - Country:US
Mailing Address - Phone:775-786-6770
Mailing Address - Fax:
Practice Address - Street 1:10085 DOUBLE R BLVD
Practice Address - Street 2:STE 310
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89521
Practice Address - Country:US
Practice Address - Phone:775-982-7260
Practice Address - Fax:775-982-7268
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA943363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVP00426676OtherRAILROAD MEDICARE
12780456OtherCAQH