Provider Demographics
NPI:1841888484
Name:BENODIN, LESLY MATTHEW (PA-C)
Entity type:Individual
Prefix:
First Name:LESLY
Middle Name:MATTHEW
Last Name:BENODIN
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 1:404 FM 3179 RD
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77340-2068
Mailing Address - Country:US
Mailing Address - Phone:936-900-6007
Mailing Address - Fax:
Practice Address - Street 1:1289 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77840-1559
Practice Address - Country:US
Practice Address - Phone:936-900-6007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-08
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA16911363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant