Healthcare Provider Details

I. General information

NPI: 1396790028
Provider Name (Legal Business Name): BENJAMIN SPOONER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 12/01/2022
Certification Date: 12/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1978 CROMPOND RD
CORTLANDT MNR NY
10567-4111
US

IV. Provider business mailing address

2649 STRANG BLVD SUITE 304
YORKTOWN HEIGHTS NY
10598-2939
US

V. Phone/Fax

Practice location:
  • Phone: 914-736-0703
  • Fax:
Mailing address:
  • Phone: 914-739-0087
  • Fax: 914-737-1714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number011053
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: