Provider Demographics
NPI:1285693481
Name:BENSON, NATHAN (MD)
Entity type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:
Last Name:BENSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 N RIM DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3128
Mailing Address - Country:US
Mailing Address - Phone:928-774-8201
Mailing Address - Fax:928-779-6139
Practice Address - Street 1:1300 N RIM DR
Practice Address - Street 2:SUITE C
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3128
Practice Address - Country:US
Practice Address - Phone:928-774-8201
Practice Address - Fax:928-779-6139
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11943208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ204777Medicaid
AZ204777Medicaid
C99127Medicare UPIN