Provider Demographics
NPI:1366844995
Name:BENCOSME, BETTY (PAT)
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:
Last Name:BENCOSME
Suffix:
Gender:F
Credentials:PAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3276 GREENWALD WAY N
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-0728
Mailing Address - Country:US
Mailing Address - Phone:407-944-0999
Mailing Address - Fax:407-935-0691
Practice Address - Street 1:3276 GREENWALD WAY N
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-0728
Practice Address - Country:US
Practice Address - Phone:407-944-0999
Practice Address - Fax:407-935-0691
Is Sole Proprietor?:No
Enumeration Date:2014-09-26
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPAT9108277363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPAT9108277OtherFLORIDA LICENSE NUMBER