Provider Demographics
NPI:1275163529
Name:BENJAMIN, ERIC SAMUEL (PA - C)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:SAMUEL
Last Name:BENJAMIN
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 1:6355 WALKER LN STE 303
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22310-3247
Mailing Address - Country:US
Mailing Address - Phone:703-971-0505
Mailing Address - Fax:703-971-0508
Practice Address - Street 1:6355 WALKER LN STE 303
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22310-3247
Practice Address - Country:US
Practice Address - Phone:703-971-0505
Practice Address - Fax:703-971-0508
Is Sole Proprietor?:No
Enumeration Date:2020-01-24
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA2228363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVPA2228OtherSTATE LICENSE
VA0110007765OtherSTATE LICENSE
NV1275163529Medicaid