Provider Demographics
NPI:1710496047
Name:DEDRICKSON, BENJAMIN T (PA-C)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:T
Last Name:DEDRICKSON
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 1:1489 S HIGLEY RD STE 101
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-4777
Mailing Address - Country:US
Mailing Address - Phone:480-457-8800
Mailing Address - Fax:
Practice Address - Street 1:1580 W ANTELOPE DR STE 110
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-1153
Practice Address - Country:US
Practice Address - Phone:801-807-7699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6854207Q00000X
UT10982649-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine