Provider Demographics
NPI:1902132376
Name:EITHUN, BENJAMIN LAYNE (CRNP)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:LAYNE
Last Name:EITHUN
Suffix:
Gender:
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:937 MERRI HILL DR
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:WI
Mailing Address - Zip Code:53575-1001
Mailing Address - Country:US
Mailing Address - Phone:608-212-9866
Mailing Address - Fax:
Practice Address - Street 1:E401 23RD ST
Practice Address - Street 2:
Practice Address - City:BRODHEAD
Practice Address - State:WI
Practice Address - Zip Code:53520-2203
Practice Address - Country:US
Practice Address - Phone:262-701-7257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-20
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5064363L00000X
IAC178097363LP0200X
MARN1000896363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner