Healthcare Provider Details

I. General information

NPI: 1134095235
Provider Name (Legal Business Name): BENJAMIN LYAL JOSEPH SCRIVENER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2025
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 WESLEY DR
MEMPHIS TN
38116-6499
US

IV. Provider business mailing address

132 KAYLA DR
SOUTHAVEN MS
38671-1806
US

V. Phone/Fax

Practice location:
  • Phone: 901-516-3700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7387
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code146L00000X
TaxonomyParamedic
License Number
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: