Provider Demographics
NPI:1770219701
Name:BENJAMIN, PAUL ANSON
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:ANSON
Last Name:BENJAMIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1854 PORTCASTLE CIR
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-4747
Mailing Address - Country:US
Mailing Address - Phone:786-877-0503
Mailing Address - Fax:
Practice Address - Street 1:1854 PORTCASTLE CIR
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-4747
Practice Address - Country:US
Practice Address - Phone:786-877-0503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-01
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11021024363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health