Provider Demographics
NPI:1255687570
Name:BENAVIDES, ESTEBAN A
Entity Type:Individual
Prefix:
First Name:ESTEBAN
Middle Name:A
Last Name:BENAVIDES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ESTEBAN
Other - Middle Name:A
Other - Last Name:BENAVIDES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:4850 37TH ST APT 2G
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-1927
Mailing Address - Country:US
Mailing Address - Phone:347-393-7315
Mailing Address - Fax:
Practice Address - Street 1:8616 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:WOODHAVEN
Practice Address - State:NY
Practice Address - Zip Code:11421-2042
Practice Address - Country:US
Practice Address - Phone:718-805-0037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP84971363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical