Provider Demographics
NPI:1922606854
Name:GLEASON, BENJAMIN CROSBY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:CROSBY
Last Name:GLEASON
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 1:132 OLSEN CT
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:NY
Mailing Address - Zip Code:12549-1736
Mailing Address - Country:US
Mailing Address - Phone:845-649-7952
Mailing Address - Fax:
Practice Address - Street 1:7901 4TH AVE STE A20
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-3957
Practice Address - Country:US
Practice Address - Phone:718-491-5800
Practice Address - Fax:718-748-2151
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NY025915363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty