Provider Demographics
NPI:1790758076
Name:BENAC, TIMOTHY R (PA-C)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:R
Last Name:BENAC
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 1:7870W US HIGHWAY 2
Mailing Address - Street 2:
Mailing Address - City:MANISTIQUE
Mailing Address - State:MI
Mailing Address - Zip Code:49854-8992
Mailing Address - Country:US
Mailing Address - Phone:906-341-1876
Mailing Address - Fax:
Practice Address - Street 1:7870W US HIGHWAY 2
Practice Address - Street 2:
Practice Address - City:MANISTIQUE
Practice Address - State:MI
Practice Address - Zip Code:49854-8992
Practice Address - Country:US
Practice Address - Phone:906-341-1876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9953363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN160186500Medicaid
MN160186500Medicaid
Q30580Medicare UPIN