Provider Demographics
NPI:1124614953
Name:BENNER, AUSTIN CHARLES (PA-C)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:CHARLES
Last Name:BENNER
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 1:7 DOCK HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17842-8910
Mailing Address - Country:US
Mailing Address - Phone:570-837-2123
Mailing Address - Fax:570-837-2185
Practice Address - Street 1:1 DOCK HILL RD
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:PA
Practice Address - Zip Code:17842-8910
Practice Address - Country:US
Practice Address - Phone:570-837-5889
Practice Address - Fax:570-837-6600
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-16
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA062295363A00000X
PAOA005540363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1038793050001Medicaid
PA1N4857OtherMEDICARE