1578775748 NPI number — ROLAND D BENIGNO PA-C

Table of content: ROLAND D BENIGNO PA-C (NPI 1578775748)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578775748 NPI number — ROLAND D BENIGNO PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENIGNO
Provider First Name:
ROLAND
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578775748
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3030 N CENTRAL AVE STE 1001
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85012-2716
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-406-4786
Provider Business Mailing Address Fax Number:
916-636-4358

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
485 S DOBSON RD STE 110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHANDLER
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-728-4470
Provider Business Practice Location Address Fax Number:
480-728-4499
Provider Enumeration Date:
05/03/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  2350 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: 2350 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3Z3993 . This is a "HEALTHNET" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 501936 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".