Provider Demographics
NPI:1912105164
Name:HENNESSEE, BENJAMIN THOMAS (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:THOMAS
Last Name:HENNESSEE
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 1:508 HARDSCRABBLE DR
Mailing Address - Street 2:
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:NC
Mailing Address - Zip Code:27278-9767
Mailing Address - Country:US
Mailing Address - Phone:301-318-6688
Mailing Address - Fax:
Practice Address - Street 1:100 W PARKVIEW DR
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-5923
Practice Address - Country:US
Practice Address - Phone:252-438-3549
Practice Address - Fax:252-438-2084
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010--02477363AM0700X, 363AM0700X
MDC03541363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8102695Medicaid
NC8102695Medicaid