Provider Demographics
NPI:1861417453
Name:BENON, ROBERT JOHN (MSN, FNP)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOHN
Last Name:BENON
Suffix:
Gender:M
Credentials:MSN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1880A CALLE QUEDO
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-5433
Mailing Address - Country:US
Mailing Address - Phone:505-438-9139
Mailing Address - Fax:
Practice Address - Street 1:2100 YUCCA ST
Practice Address - Street 2:STUDENT SERVICES BLDG.
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-5456
Practice Address - Country:US
Practice Address - Phone:505-467-2439
Practice Address - Fax:505-467-2989
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR21020363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00069174Medicaid
NM00069174Medicaid