Provider Demographics
NPI:1316530041
Name:BENJAMIN, ELISE KATHRYN
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:KATHRYN
Last Name:BENJAMIN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2151 OLD BRICK RD.
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-3849
Mailing Address - Country:US
Mailing Address - Phone:804-727-6800
Mailing Address - Fax:
Practice Address - Street 1:2151 OLD BRICK RD
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-5837
Practice Address - Country:US
Practice Address - Phone:804-727-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-13
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110009273363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant