Provider Demographics
NPI:1316914682
Name:EBUEN, BENEDICT LABRADOR (PA-C)
Entity type:Individual
Prefix:
First Name:BENEDICT
Middle Name:LABRADOR
Last Name:EBUEN
Suffix:
Gender:M
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 1:1536 N JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-6525
Mailing Address - Country:US
Mailing Address - Phone:904-475-5800
Mailing Address - Fax:904-301-2502
Practice Address - Street 1:1536 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6525
Practice Address - Country:US
Practice Address - Phone:904-475-5800
Practice Address - Fax:904-301-2502
Is Sole Proprietor?:No
Enumeration Date:2006-03-04
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101700363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA657342142AMedicaid
FL2911027-00Medicaid
FL970021910Medicare PIN
FLE6289ZMedicare PIN
GA657342142AMedicaid