Healthcare Provider Details

I. General information

NPI: 1750973301
Provider Name (Legal Business Name): BENJAMIN R CRISP PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2021
Last Update Date: 03/19/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5511 VIRGINIA WAY STE 300
BRENTWOOD TN
37027-7611
US

IV. Provider business mailing address

5511 VIRGINA WAY STE 300
BRENTWOOD TN
37027-7611
US

V. Phone/Fax

Practice location:
  • Phone: 615-994-1000
  • Fax: 615-994-0100
Mailing address:
  • Phone: 615-994-1000
  • Fax: 615-994-0100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA16865
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110009244
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110009244
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number28880
License Number StateNY
# 5
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4462
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: