Provider Demographics
NPI:1104227669
Name:PANTHER, BENJAMIN COLEMAN (PA-C)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:COLEMAN
Last Name:PANTHER
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 1:3240 NE 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-2408
Mailing Address - Country:US
Mailing Address - Phone:360-838-2440
Mailing Address - Fax:360-838-2450
Practice Address - Street 1:3240 NE 3RD AVE
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-2408
Practice Address - Country:US
Practice Address - Phone:360-729-8234
Practice Address - Fax:360-293-3337
Is Sole Proprietor?:No
Enumeration Date:2014-09-15
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60698188363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant