Healthcare Provider Details

I. General information

NPI: 1417527649
Provider Name (Legal Business Name): BENJAMIN PENN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2021
Last Update Date: 02/06/2023
Certification Date: 02/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 OLD COUNTRY RD
RIVERHEAD NY
11901-2198
US

IV. Provider business mailing address

170 OLD COUNTRY RD
RIVERHEAD NY
11901-2198
US

V. Phone/Fax

Practice location:
  • Phone: 631-208-4460
  • Fax:
Mailing address:
  • Phone: 631-208-4460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number026947
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: