Provider Demographics
NPI:1821645870
Name:ATWOOD, BENJAMIN J (PA)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:J
Last Name:ATWOOD
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 1:3446 S 15TH E
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8262
Mailing Address - Country:US
Mailing Address - Phone:208-522-6335
Mailing Address - Fax:208-522-0550
Practice Address - Street 1:3446 S 15TH E
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8262
Practice Address - Country:US
Practice Address - Phone:208-522-6335
Practice Address - Fax:208-522-0550
Is Sole Proprietor?:No
Enumeration Date:2019-08-23
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA1770363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPA1770OtherLICENSE