Provider Demographics
NPI:1205461522
Name:SMITH, BENJAMIN A
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:A
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1724 POINTE WOODWORTH DR NE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98422-3480
Mailing Address - Country:US
Mailing Address - Phone:253-517-5466
Mailing Address - Fax:
Practice Address - Street 1:100 WASHINGTON AVE S STE 900
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55401-2511
Practice Address - Country:US
Practice Address - Phone:866-492-5336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-06
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60575277163W00000X
WAAP61054509363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse