Provider Demographics
NPI:1437196896
Name:BENKLEY, BRUCE A (PA-C)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:A
Last Name:BENKLEY
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 1:1400 W ICE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:IRON RIVER
Mailing Address - State:MI
Mailing Address - Zip Code:49935-9526
Mailing Address - Country:US
Mailing Address - Phone:906-265-6121
Mailing Address - Fax:
Practice Address - Street 1:1328 US HIGHWAY 2
Practice Address - Street 2:
Practice Address - City:CRYSTAL FALLS
Practice Address - State:MI
Practice Address - Zip Code:49920-1045
Practice Address - Country:US
Practice Address - Phone:906-875-4486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI588-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI970028874OtherMEDICARE RAILROAD
WI42931900Medicaid
WI970028873OtherMEDICARE RAILROAD
MI1437196896Medicaid
MI1437196896Medicaid
MIM31750045Medicare Oscar/Certification