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General NPI Number Information
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NPI Number | 1477992592
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Entity Type | Individual
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Provider Name | STANFORD BENJAMIN GAMMON P.A.
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Gender | Male
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Dates
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Enumeration Date | 06/21/2013
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Last Update Date | 07/07/2022
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Provider Practice Location Address
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Address Line | 3345 POTOMAC WAY
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City | IDAHO FALLS
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State | ID
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Zip | 83404-4978
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Country | US
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Telephone | 208-552-7572
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Fax | 208-552-7312
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Provider Business Mailing Address
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Address Line | PO BOX 277381
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City | ATLANTA
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State | GA
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Zip | 30384-7381
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Country | US
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Telephone |
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Fax |
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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 | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | PA-1328
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License Number State | ID
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