Provider Demographics
NPI:1649508334
Name:STOUT, BENTON REAL (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:BENTON
Middle Name:REAL
Last Name:STOUT
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 SPRING GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-2050
Mailing Address - Country:US
Mailing Address - Phone:951-544-9589
Mailing Address - Fax:
Practice Address - Street 1:1850 SPRING GARDEN ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2050
Practice Address - Country:US
Practice Address - Phone:951-544-9589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-18
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20699363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant