Provider Demographics
NPI:1891763165
Name:LOGGAINS, BENTON C (PA-C)
Entity Type:Individual
Prefix:
First Name:BENTON
Middle Name:C
Last Name:LOGGAINS
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:PO BOX 11230
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72917-1230
Mailing Address - Country:US
Mailing Address - Phone:479-709-7000
Mailing Address - Fax:479-709-7051
Practice Address - Street 1:3501 W E KNIGHT DRIVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903
Practice Address - Country:US
Practice Address - Phone:479-709-6700
Practice Address - Fax:479-709-6751
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA276363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR200022460AOtherOKLAHOMA MEDICAID
ARQ06103Medicare UPIN
OK248607401Medicare PIN
AR5L162P112Medicare PIN