Provider Demographics
NPI:1023788536
Name:REETZ, BENJAMIN DONALD (PA-C)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:DONALD
Last Name:REETZ
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 140
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VT
Mailing Address - Zip Code:05477-0140
Mailing Address - Country:US
Mailing Address - Phone:603-359-0304
Mailing Address - Fax:
Practice Address - Street 1:4567 E 9TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80220-3908
Practice Address - Country:US
Practice Address - Phone:303-320-2121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-16
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
COPA.0007040363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty