Provider Demographics
NPI:1255874079
Name:BENITEZ KRUIDENIER, SANDRA LORENA (PA-C)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:LORENA
Last Name:BENITEZ KRUIDENIER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:LORENA
Other - Last Name:BENITEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:1221 MADISON ST
Practice Address - Street 2:STE 1020
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-1380
Practice Address - Country:US
Practice Address - Phone:206-215-2658
Practice Address - Fax:206-991-2363
Is Sole Proprietor?:No
Enumeration Date:2016-11-28
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61115668363A00000X
TXPA12774363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1255874079Medicaid
TX401359101Medicaid