Provider Demographics
NPI:1740369750
Name:KLENNERT, BENJAMIN J (PA C)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:J
Last Name:KLENNERT
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1526 MILEGROUND RD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-3745
Mailing Address - Country:US
Mailing Address - Phone:304-777-4044
Mailing Address - Fax:304-292-9578
Practice Address - Street 1:1526 MILEGROUND RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-3745
Practice Address - Country:US
Practice Address - Phone:304-296-2395
Practice Address - Fax:304-413-0055
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00944363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVPA19705Medicare PIN
WVKLPA19706Medicare PIN
P68545Medicare UPIN
WVKLPA19702Medicare PIN