Provider Demographics
NPI:1386632586
Name:BENGE, TIMOTHY FRED (PA-C)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:FRED
Last Name:BENGE
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 1:2880 COMMONWEALTH DR UNIT 418
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:TN
Mailing Address - Zip Code:37174-3177
Mailing Address - Country:US
Mailing Address - Phone:615-614-1708
Mailing Address - Fax:
Practice Address - Street 1:2880 COMMONWEALTH DR UNIT 418
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:TN
Practice Address - Zip Code:37174-3177
Practice Address - Country:US
Practice Address - Phone:615-614-1708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103774363AM0700X
TN3158363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC103774OtherLICENSE NUMBER
NC103774OtherLICENSE NUMBER
2759111Medicare PIN