Provider Demographics
NPI:1780071696
Name:HERENDEEN, BENJAMIN (PA-C)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:HERENDEEN
Suffix:
Gender:M
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 1:600 W GOODALE ST
Mailing Address - Street 2:#539
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-1597
Mailing Address - Country:US
Mailing Address - Phone:440-969-5851
Mailing Address - Fax:
Practice Address - Street 1:610 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-2125
Practice Address - Country:US
Practice Address - Phone:937-382-6611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-17
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004350363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant