Provider Demographics
NPI:1346794732
Name:BENDA, GARY ALAN JR (MPAS)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:ALAN
Last Name:BENDA
Suffix:JR
Gender:M
Credentials:MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 HULON LN
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-4841
Mailing Address - Country:US
Mailing Address - Phone:803-935-8410
Mailing Address - Fax:803-936-7816
Practice Address - Street 1:222 E MEDICAL LN STE 100&200
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4847
Practice Address - Country:US
Practice Address - Phone:803-935-8410
Practice Address - Fax:803-936-7816
Is Sole Proprietor?:No
Enumeration Date:2016-08-15
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2579363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2733PAMedicaid
SC2733PAMedicaid