Provider Demographics
NPI:1881767556
Name:BENTON, MICHAEL J (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:BENTON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1919 E MEMORIAL RD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73131-1253
Mailing Address - Country:US
Mailing Address - Phone:405-749-7099
Mailing Address - Fax:405-216-5872
Practice Address - Street 1:1919 E MEMORIAL RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73131-1253
Practice Address - Country:US
Practice Address - Phone:405-749-7099
Practice Address - Fax:405-216-5872
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2015-12-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK1068363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP39683Medicare UPIN