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General NPI Number Information
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NPI Number | 1104227669
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Entity Type | Individual
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Provider Name | BENJAMIN COLEMAN PANTHER PA-C
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Gender | Male
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Dates
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Enumeration Date | 09/15/2014
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Last Update Date | 11/25/2020
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Provider Practice Location Address
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Address Line | 3240 NE 3RD AVE
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City | CAMAS
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State | WA
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Zip | 98607-2408
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Country | US
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Telephone | 360-729-8234
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Fax | 360-293-3337
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Provider Business Mailing Address
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Address Line | 3240 NE 3RD AVE
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City | CAMAS
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State | WA
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Zip | 98607-2408
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Country | US
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Telephone | 360-838-2440
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Fax | 360-838-2450
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA60698188
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License Number State | WA
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