Provider Demographics
NPI:1316969397
Name:BENZ, SHAB (PA)
Entity type:Individual
Prefix:
First Name:SHAB
Middle Name:
Last Name:BENZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SHAB
Other - Middle Name:
Other - Last Name:NAINI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:20 GRAND ST FL 3
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990-1035
Mailing Address - Country:US
Mailing Address - Phone:845-368-0330
Mailing Address - Fax:845-987-5979
Practice Address - Street 1:20 GRAND ST
Practice Address - Street 2:3RD FL
Practice Address - City:WARWICK
Practice Address - State:NY
Practice Address - Zip Code:10990-1035
Practice Address - Country:US
Practice Address - Phone:845-987-3906
Practice Address - Fax:845-987-5979
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00150100363AM0700X
NY011573363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ103119MBQMedicare PIN
Q71101Medicare UPIN
NYQ71101Medicare UPIN