Provider Demographics
NPI:1649527664
Name:BENSON, ERIC GUST (RN, FNP)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:GUST
Last Name:BENSON
Suffix:
Gender:M
Credentials:RN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 E FAIRMONT AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-0207
Mailing Address - Country:US
Mailing Address - Phone:209-918-7033
Mailing Address - Fax:
Practice Address - Street 1:12700 WELCH ST
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CA
Practice Address - Zip Code:95386-8765
Practice Address - Country:US
Practice Address - Phone:209-874-2345
Practice Address - Fax:209-874-3926
Is Sole Proprietor?:No
Enumeration Date:2012-08-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA492134163W00000X
CA13248363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMB4043624OtherDEA NUMBER