Provider Demographics
NPI:1255304473
Name:JETER, BENJAMIN ALAN (PA)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:ALAN
Last Name:JETER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 GADSDEN HWY
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35235-3134
Mailing Address - Country:US
Mailing Address - Phone:205-838-3900
Mailing Address - Fax:205-838-3906
Practice Address - Street 1:1801 GADSDEN HWY
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235-3134
Practice Address - Country:US
Practice Address - Phone:205-838-3900
Practice Address - Fax:205-838-3906
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA-160363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51520839OtherBLUE CROSS BLUE SHIELD
S74005Medicare UPIN
AL51520839OtherBLUE CROSS BLUE SHIELD