Healthcare Provider Details

I. General information

NPI: 1437455318
Provider Name (Legal Business Name): BENJAMIN DON BURTENSHAW PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2011
Last Update Date: 01/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

267 N CANYON DR
GOODING ID
83330-5500
US

IV. Provider business mailing address

611 PINE ST
GOODING ID
83330-1755
US

V. Phone/Fax

Practice location:
  • Phone: 208-934-4433
  • Fax:
Mailing address:
  • Phone: 208-220-6268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number4810
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-898
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: