Provider Demographics
NPI:1932540861
Name:ENSELL, BENJAMIN MICHAEL (PA-C)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:MICHAEL
Last Name:ENSELL
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 1:5821 S WILLIAMSON BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-6102
Mailing Address - Country:US
Mailing Address - Phone:386-231-6325
Mailing Address - Fax:
Practice Address - Street 1:5821 S WILLIAMSON BLVD STE 202
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32128-6102
Practice Address - Country:US
Practice Address - Phone:386-231-6325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-08
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107261363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015492900Medicaid
FLPA9107261OtherPHYSICIAN ASSISTANT LICENSE
FLPA9107261OtherPHYSICIAN ASSISTANT LICENSE