Provider Demographics
NPI:1588796486
Name:BENECKI, ELEANOR ALICE (PA)
Entity Type:Individual
Prefix:
First Name:ELEANOR
Middle Name:ALICE
Last Name:BENECKI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 SW OAK ST
Mailing Address - Street 2:210
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-1817
Mailing Address - Country:US
Mailing Address - Phone:503-988-3674
Mailing Address - Fax:503-988-3676
Practice Address - Street 1:426 SW STARK ST
Practice Address - Street 2:8TH FLOOR
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-2347
Practice Address - Country:US
Practice Address - Phone:503-988-3674
Practice Address - Fax:503-988-3676
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00311363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR116140Medicare ID - Type Unspecified
ORP91497Medicare UPIN