Provider Demographics
NPI:1457617383
Name:OLMEDO, BENJAMIN (PA-C)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:OLMEDO
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 1:217 W CENTRAL AVE STE G
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-2830
Mailing Address - Country:US
Mailing Address - Phone:805-735-4292
Mailing Address - Fax:805-735-4293
Practice Address - Street 1:217 W CENTRAL AVE STE G
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-2830
Practice Address - Country:US
Practice Address - Phone:805-735-4292
Practice Address - Fax:805-735-4293
Is Sole Proprietor?:No
Enumeration Date:2012-04-04
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1039363A00000X
CAPA52451363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMDA0484Medicaid
AKMDA0484Medicaid