Provider Demographics
NPI:1508383738
Name:DRALEAU, BENJAMIN PHILIP (PA-C)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:PHILIP
Last Name:DRALEAU
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 1:10428 S JORDAN GTWY UNIT 223
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-5402
Mailing Address - Country:US
Mailing Address - Phone:360-790-8201
Mailing Address - Fax:
Practice Address - Street 1:5169 S COTTONWOOD ST STE 320
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6768
Practice Address - Country:US
Practice Address - Phone:801-507-3380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-28
Last Update Date:2017-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10502233-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant