Provider Demographics
NPI:1902551146
Name:BENTON, MICAELA (PA-C)
Entity Type:Individual
Prefix:
First Name:MICAELA
Middle Name:
Last Name:BENTON
Suffix:
Gender:F
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 1:4071 TATES CREEK CENTRE DR STE 202
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-3094
Mailing Address - Country:US
Mailing Address - Phone:859-226-0206
Mailing Address - Fax:859-226-0207
Practice Address - Street 1:4071 TATES CREEK CENTRE DR STE 202
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40517-3094
Practice Address - Country:US
Practice Address - Phone:859-226-0206
Practice Address - Fax:859-226-0207
Is Sole Proprietor?:No
Enumeration Date:2022-02-16
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA3063363A00000X
KYTC272363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant