Provider Demographics
NPI:1629736459
Name:WINN, BENJAMIN KEITH (PA-C)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:KEITH
Last Name:WINN
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 1:330 SNOW CAP RD APT D
Mailing Address - Street 2:
Mailing Address - City:TONTITOWN
Mailing Address - State:AR
Mailing Address - Zip Code:72762-4537
Mailing Address - Country:US
Mailing Address - Phone:479-365-0368
Mailing Address - Fax:
Practice Address - Street 1:1261 E TULSA AVE
Practice Address - Street 2:
Practice Address - City:KANSAS
Practice Address - State:OK
Practice Address - Zip Code:74347-7026
Practice Address - Country:US
Practice Address - Phone:918-868-2175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant