Provider Demographics
NPI:1720611544
Name:BENSON, KYLE ELIZABETH (PA)
Entity Type:Individual
Prefix:MISS
First Name:KYLE
Middle Name:ELIZABETH
Last Name:BENSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4985 STABLEGATE CT
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30028-7967
Mailing Address - Country:US
Mailing Address - Phone:770-856-4704
Mailing Address - Fax:
Practice Address - Street 1:11601 MONTGOMERY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-2660
Practice Address - Country:US
Practice Address - Phone:505-814-1995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-20
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NMPA2023-0035363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant