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 1:109 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH WEST CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64863-9417
Mailing Address - Country:US
Mailing Address - Phone:417-762-3287
Mailing Address - Fax:417-762-3255
Practice Address - Street 1:109 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SOUTH WEST CITY
Practice Address - State:MO
Practice Address - Zip Code:64863-9417
Practice Address - Country:US
Practice Address - Phone:417-762-3287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-29
Last Update Date:2025-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4746363A00000X
AR1037363A00000X
MO2025037891363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant