Provider Demographics
NPI:1609247477
Name:DAVIS, BENJAMIN RAY (PA)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:RAY
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 W LA VETA AVE STE 750
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4312
Mailing Address - Country:US
Mailing Address - Phone:714-639-9401
Mailing Address - Fax:
Practice Address - Street 1:1010 W LA VETA AVE STE 750
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4312
Practice Address - Country:US
Practice Address - Phone:714-639-9401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52963363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGRP. NPI: 1912919804OtherMEDI-CAL
CA1912919804OtherTYPE 2 NPI
CA52963OtherMEDICAL LICENSE
CA1912919804OtherTYPE 2 NPI
CA52963OtherMEDICAL LICENSE