Provider Demographics
NPI:1598781783
Name:BROGAN, BENJAMIN J (PA-C)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:J
Last Name:BROGAN
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:PO BOX 639969
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-9969
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5875 BREMO RD STE 400B
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1928
Practice Address - Country:US
Practice Address - Phone:804-287-7840
Practice Address - Fax:804-287-7845
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
VA0110001372363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06778OtherGROUP PTAN
P36048Medicare UPIN
970000525Medicare ID - Type Unspecified