Provider Demographics
NPI:1932540861
Name:ENSELL, BENJAMIN MICHAEL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:MICHAEL
Last Name:ENSELL
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 1:4612 N HABANA AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-7101
Mailing Address - Country:US
Mailing Address - Phone:813-840-3526
Mailing Address - Fax:
Practice Address - Street 1:4612 N HABANA AVE FL 1
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-7101
Practice Address - Country:US
Practice Address - Phone:813-840-3526
Practice Address - Fax:813-840-3555
Is Sole Proprietor?:No
Enumeration Date:2013-07-08
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107261363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9107261OtherPHYSICIAN ASSISTANT LICENSE
FL015492900Medicaid
FLPA9107261OtherPHYSICIAN ASSISTANT LICENSE