Provider Demographics
NPI:1992076111
Name:TYAU, BENJAMIN C (PA-C)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:C
Last Name:TYAU
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 1:1321 N MARTINGALE RD
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-1701
Mailing Address - Country:US
Mailing Address - Phone:480-452-6660
Mailing Address - Fax:
Practice Address - Street 1:193 BATH RD
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011
Practice Address - Country:US
Practice Address - Phone:207-424-2272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-19
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5007363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant