Provider Demographics
NPI:1396790028
Name:SPOONER, BENJAMIN (PA)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:SPOONER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2649 STRANG BLVD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:YORKTOWN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:10598-2939
Mailing Address - Country:US
Mailing Address - Phone:914-739-0087
Mailing Address - Fax:914-737-1714
Practice Address - Street 1:1978 CROMPOND RD
Practice Address - Street 2:
Practice Address - City:CORTLANDT MNR
Practice Address - State:NY
Practice Address - Zip Code:10567-4111
Practice Address - Country:US
Practice Address - Phone:914-736-0703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011053363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00330295OtherRAILROAD MEDICARE
NYP00330295OtherRAILROAD MEDICARE
NY4682510004Medicare NSC
NY4682510003Medicare NSC
NY4682510001Medicare NSC
NYQ70091Medicare UPIN