Provider Demographics
NPI:1215496575
Name:DOUGLAS, BENJAMIN (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UNIT 5071 BOX MDG
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96328-5071
Mailing Address - Country:US
Mailing Address - Phone:315-225-5207
Mailing Address - Fax:
Practice Address - Street 1:UNIT 5071 BOX MDG
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96328-5071
Practice Address - Country:US
Practice Address - Phone:315-225-5207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-17
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant