Provider Demographics
NPI:1477159200
Name:BENJAMIN, LORA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LORA
Middle Name:
Last Name:BENJAMIN
Suffix:
Gender:F
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 1:7673 W HIDDEN LK
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:MI
Mailing Address - Zip Code:48872-8147
Mailing Address - Country:US
Mailing Address - Phone:517-282-2720
Mailing Address - Fax:
Practice Address - Street 1:200 N CALEDONIA DR
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-8844
Practice Address - Country:US
Practice Address - Phone:989-729-4848
Practice Address - Fax:989-729-4849
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-08
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIPENDING363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant