Provider Demographics
NPI:1881328045
Name:BLEDSOE, BENJAMIN SCOTT (MA)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:SCOTT
Last Name:BLEDSOE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5423 15TH AVE NE APT G106
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98156
Mailing Address - Country:US
Mailing Address - Phone:626-993-4114
Mailing Address - Fax:
Practice Address - Street 1:9040 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-3852
Practice Address - Country:US
Practice Address - Phone:253-968-2820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2024-01-19
Deactivation Date:2023-08-09
Deactivation Code:
Reactivation Date:2023-11-08
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program