Provider Demographics
NPI:1275163529
Name:BENJAMIN, ERIC SAMUEL (PA - C)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:SAMUEL
Last Name:BENJAMIN
Suffix:
Gender:
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 1:6354 WALKER LN STE 350
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22310-3256
Mailing Address - Country:US
Mailing Address - Phone:703-678-1881
Mailing Address - Fax:833-973-3867
Practice Address - Street 1:1326 EISENHOWER DR BLDG 2
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-3928
Practice Address - Country:US
Practice Address - Phone:912-354-6303
Practice Address - Fax:912-355-8655
Is Sole Proprietor?:No
Enumeration Date:2020-01-24
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA2228363A00000X
VA0110007765363A00000X
GA12238363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0110007765OtherSTATE LICENSE
NVPA2228OtherSTATE LICENSE
NV1275163529Medicaid