Basic Information
| Provider Information | |||||||||
| NPI: | 1316915259 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENJAMIN | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | A, | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1060 DAY HILL RD | ||||||||
| Address2: | |||||||||
| City: | WINDSOR | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060955719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606962450 | ||||||||
| FaxNumber: | 8606962460 | ||||||||
| Practice Location | |||||||||
| Address1: | 1060 DAY HILL RD | ||||||||
| Address2: | |||||||||
| City: | WINDSOR | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060955719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606832690 | ||||||||
| FaxNumber: | 8606832670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 12/19/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 000069 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1316915259 | 01 | CT | NPI | OTHER |