Provider Demographics
NPI:1336179852
Name:BENAK, JONATHAN JAMES (PA-C)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:JAMES
Last Name:BENAK
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 1:615 OCEAN ST
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-4005
Mailing Address - Country:US
Mailing Address - Phone:831-425-7991
Mailing Address - Fax:831-425-7346
Practice Address - Street 1:615 OCEAN ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-4005
Practice Address - Country:US
Practice Address - Phone:831-425-7991
Practice Address - Fax:831-425-7346
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15143363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA15143Medicaid
CAPA15143Medicaid
CA0PA151433Medicare PIN