Provider Demographics
NPI:1871934851
Name:KOLNER, BENJAMIN J (PA-C)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:J
Last Name:KOLNER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3385 DEXTER CT STE 103
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3471
Mailing Address - Country:US
Mailing Address - Phone:563-441-5860
Mailing Address - Fax:563-441-5865
Practice Address - Street 1:3385 DEXTER CT STE 103
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3471
Practice Address - Country:US
Practice Address - Phone:563-441-5860
Practice Address - Fax:563-441-5865
Is Sole Proprietor?:No
Enumeration Date:2013-07-08
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004768363A00000X
IA002418363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1871934851Medicaid
IA719260594Medicare PIN