Provider Demographics
NPI:1437455318
Name:BURTENSHAW, BENJAMIN DON (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:DON
Last Name:BURTENSHAW
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 1:611 PINE ST
Mailing Address - Street 2:
Mailing Address - City:GOODING
Mailing Address - State:ID
Mailing Address - Zip Code:83330-1755
Mailing Address - Country:US
Mailing Address - Phone:208-220-6268
Mailing Address - Fax:
Practice Address - Street 1:267 N CANYON DR
Practice Address - Street 2:
Practice Address - City:GOODING
Practice Address - State:ID
Practice Address - Zip Code:83330-5500
Practice Address - Country:US
Practice Address - Phone:208-934-4433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-10
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4810363AM0700X
IDPA-898363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical