Provider Demographics
NPI:1336474402
Name:BENSON, KIMBERLY CHRISTINE (PA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:CHRISTINE
Last Name:BENSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:PONCHATOULA
Mailing Address - State:LA
Mailing Address - Zip Code:70454-2532
Mailing Address - Country:US
Mailing Address - Phone:985-370-7546
Mailing Address - Fax:985-370-7765
Practice Address - Street 1:180 N 5TH ST
Practice Address - Street 2:
Practice Address - City:PONCHATOULA
Practice Address - State:LA
Practice Address - Zip Code:70454-2532
Practice Address - Country:US
Practice Address - Phone:985-370-7546
Practice Address - Fax:985-370-7765
Is Sole Proprietor?:No
Enumeration Date:2009-10-07
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200302363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1807311Medicaid
LA1807311Medicaid
LA5DE56PC40Medicare PIN
LA5DL13PC74Medicare PIN