Provider Demographics
NPI:1992195184
Name:SHIVAR, BENJAMIN (PA-C)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:SHIVAR
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 1:1607 SAINT JAMES CT STE 2
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5352
Mailing Address - Country:US
Mailing Address - Phone:850-878-8714
Mailing Address - Fax:850-878-2464
Practice Address - Street 1:1607 SAINT JAMES CT STE 2
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5352
Practice Address - Country:US
Practice Address - Phone:850-878-8714
Practice Address - Fax:850-878-2464
Is Sole Proprietor?:No
Enumeration Date:2015-01-27
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108528363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant