MEDICARE: MR. BENJAMIN MICHAEL ENSELL PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA9107261	FL
2	363AM0700X	Medical Physician Assistant	PA9107261	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	PA9107261	OTHER	FL	PHYSICIAN ASSISTANT LICENSE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1932540861
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BENJAMIN MICHAEL ENSELL PA-C

Provider Business Mailing Address
First Line	:	5821 S WILLIAMSON BLVD STE 202
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32128-6102
Country	:	US
Telephone Number	:	386-231-6325
Fax Number	:

Provider Business Practice Location Address
First Line	:	5821 S WILLIAMSON BLVD STE 202
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32128-6102
Country	:	US
Telephone Number	:	386-231-6325
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2013
Last Update Date	:	09/20/2024

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Directions to “ MR. BENJAMIN MICHAEL ENSELL PA-C” Practice Location

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