Provider Demographics
NPI:1881480077
Name:BENAVIDES, JUAN CARLOS (PA)
Entity type:Individual
Prefix:
First Name:JUAN CARLOS
Middle Name:
Last Name:BENAVIDES
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:JUAN
Other - Middle Name:CARLOS
Other - Last Name:BENAVIDES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3178 AZOLLA ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32808-3908
Mailing Address - Country:US
Mailing Address - Phone:386-215-0973
Mailing Address - Fax:
Practice Address - Street 1:3178 AZOLLA ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32808-3908
Practice Address - Country:US
Practice Address - Phone:386-215-0973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-16
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2517363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant