Provider Demographics
NPI:1750973301
Name:CRISP, BENJAMIN R (PA-C)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:R
Last Name:CRISP
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 1:5511 VIRGINA WAY
Mailing Address - Street 2:STE 300
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7611
Mailing Address - Country:US
Mailing Address - Phone:615-994-1000
Mailing Address - Fax:615-994-0100
Practice Address - Street 1:5511 VIRGINIA WAY
Practice Address - Street 2:STE 300
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-7611
Practice Address - Country:US
Practice Address - Phone:615-994-1000
Practice Address - Fax:615-994-0100
Is Sole Proprietor?:No
Enumeration Date:2021-02-05
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA16865363AM0700X
VA0110009244363A00000X, 363AM0700X
NY28880363AM0700X
TN4462363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical