Provider Demographics
NPI:1750985396
Name:BENNY, RESHMA THANKAM (PA-C)
Entity type:Individual
Prefix:MS
First Name:RESHMA
Middle Name:THANKAM
Last Name:BENNY
Suffix:
Gender:F
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 1:1723 CHESIL DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-4361
Mailing Address - Country:US
Mailing Address - Phone:706-361-1995
Mailing Address - Fax:
Practice Address - Street 1:1411 LANEY WALKER BLVD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0002
Practice Address - Country:US
Practice Address - Phone:706-721-6744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10084363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant