Provider Demographics
NPI:1760660633
Name:BENEDICT, AMY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:
Last Name:BENEDICT
Suffix:
Gender:F
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 1:833 MICHIGAN ST NE BLDG 102
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2578
Mailing Address - Country:US
Mailing Address - Phone:616-459-8209
Mailing Address - Fax:616-459-0313
Practice Address - Street 1:833 MICHIGAN ST NE BLDG 102
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2578
Practice Address - Country:US
Practice Address - Phone:616-459-8209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002370363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1520553Medicaid
TN4277641OtherBCBST
TN1520553Medicaid