Provider Demographics
NPI:1215309521
Name:HOUSTON, BENJAMIN TYRUS (PA)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:TYRUS
Last Name:HOUSTON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 COBURG RD STE 201
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-7487
Mailing Address - Country:US
Mailing Address - Phone:541-687-8581
Mailing Address - Fax:541-343-1411
Practice Address - Street 1:10 COBURG RD STE 201
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-7487
Practice Address - Country:US
Practice Address - Phone:541-687-8581
Practice Address - Fax:541-343-1411
Is Sole Proprietor?:No
Enumeration Date:2015-10-26
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54019363A00000X
ORPA214380363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical