Provider Demographics
NPI:1336896174
Name:ALECKSON, BENJAMIN P
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:P
Last Name:ALECKSON
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 1:2950 N CHURCH ST STE 301
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84040-6590
Mailing Address - Country:US
Mailing Address - Phone:801-771-7771
Mailing Address - Fax:833-643-2775
Practice Address - Street 1:1160 E 3900 S STE 5000
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1275
Practice Address - Country:US
Practice Address - Phone:801-261-7479
Practice Address - Fax:801-261-7429
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-02
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12859980-1206363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant