Basic Information
| Provider Information | |||||||||
| NPI: | 1871134312 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANFORD | ||||||||
| FirstName: | BENN | ||||||||
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| Credential: | MSN AGNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3570 COLLEGE ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777014679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098393118 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2929 CALDER ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777021841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098393118 | ||||||||
| FaxNumber: | 4096546921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2019 | ||||||||
| LastUpdateDate: | 10/07/2019 | ||||||||
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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 | 363LG0600X | AP143362 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.