Provider Demographics
NPI:1770507246
Name:HOLMAN, BENJAMIN M (PA)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:M
Last Name:HOLMAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 N ALLEN ROAD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-3294
Mailing Address - Country:US
Mailing Address - Phone:309-691-1400
Mailing Address - Fax:
Practice Address - Street 1:6000 N ALLEN ROAD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-3294
Practice Address - Country:US
Practice Address - Phone:309-691-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002725363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085002725Medicaid
IL085002725Medicaid
IL1291050001Medicare NSC