Provider Demographics
NPI:1477752582
Name:PEREZ, BENJAMIN (CRNA)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:PEREZ
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 44008
Mailing Address - Street 2:UFJP - PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-244-3199
Mailing Address - Fax:904-244-3425
Practice Address - Street 1:701 6TH ST S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4814
Practice Address - Country:US
Practice Address - Phone:727-823-6297
Practice Address - Fax:727-823-9502
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9195596367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA578456425AMedicaid
P00661592OtherRAILROAD MEDICARE ASSOCIATED TO GROUP CF4811
FLG4295OtherBLUE CROSS
FL3084876-00Medicaid
FLG4295OtherBLUE CROSS
FLAF311YMedicare PIN