Healthcare Provider Details

I. General information

NPI: 1730714023
Provider Name (Legal Business Name): BENJAMIN CARMACK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2020
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 HICKMAN RD
DES MOINES IA
50314-1548
US

IV. Provider business mailing address

225 E CENTER ST APT 222
DES MOINES IA
50309-1875
US

V. Phone/Fax

Practice location:
  • Phone: 515-282-2200
  • Fax:
Mailing address:
  • Phone: 970-692-4719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number110220
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: