Provider Demographics
NPI:1659383040
Name:BENJAMIN REDDICK, NICOLE DENAE (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:DENAE
Last Name:BENJAMIN REDDICK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:DENAE
Other - Last Name:BENJAMIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 THEDA CLARK MEDICAL PLZ STE 340
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-2763
Mailing Address - Country:US
Mailing Address - Phone:920-364-3600
Mailing Address - Fax:920-364-3900
Practice Address - Street 1:100 THEDA CLARK MEDICAL PLZ STE 340
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2763
Practice Address - Country:US
Practice Address - Phone:920-364-3600
Practice Address - Fax:920-364-3900
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04542363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8Y0227OtherBCBS
TX8D9496Medicare ID - Type UnspecifiedFORT WORTH
TXQ51600Medicare UPIN
TX8Y0227OtherBCBS