Provider Demographics
NPI:1447280334
Name:BENJAMIN, SABRINA ANN (MD)
Entity type:Individual
Prefix:
First Name:SABRINA
Middle Name:ANN
Last Name:BENJAMIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8339
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98509-8339
Mailing Address - Country:US
Mailing Address - Phone:360-701-2554
Mailing Address - Fax:360-438-1297
Practice Address - Street 1:1340 ALLEGHENY COURT SE
Practice Address - Street 2:SUITE 304
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98503
Practice Address - Country:US
Practice Address - Phone:360-701-2554
Practice Address - Fax:360-438-1297
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00025146207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1097732Medicaid
WA107299OtherDEPT. L & I
WAMD00025146OtherWA LICENSE
WAG25181Medicare UPIN
WAG8891177Medicare PIN
WA1097732Medicaid