Provider Demographics
NPI:1922554112
Name:HOUSLEY, BENJAMIN TIMOTHY (PA)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:TIMOTHY
Last Name:HOUSLEY
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 1:856 J CLYDE MORRIS BLVD STE A
Mailing Address - Street 2:RIVERSIDE MEDICAL GROUP
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:757-594-4006
Mailing Address - Fax:
Practice Address - Street 1:12715 WARWICK BLVD STE O
Practice Address - Street 2:COMMONWEALTH FAMILY PRACTICE
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-1800
Practice Address - Country:US
Practice Address - Phone:757-930-0091
Practice Address - Fax:757-269-4406
Is Sole Proprietor?:No
Enumeration Date:2016-08-29
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110005454363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant