Healthcare Provider Details

I. General information

NPI: 1417941501
Provider Name (Legal Business Name): LESLIE A BEBEN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 04/18/2025
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1229 ALICE DRIVE
SUMTER SC
29150
US

IV. Provider business mailing address

1229 ALICE DRIVE
SUMTER SC
29150
US

V. Phone/Fax

Practice location:
  • Phone: 803-905-2273
  • Fax: 803-905-7775
Mailing address:
  • Phone: 803-905-2273
  • Fax: 803-905-7775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number415
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: