Provider Demographics
NPI:1679167498
Name:IERARDI, BENJAMIN ROBERT (PA-C)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:ROBERT
Last Name:IERARDI
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 1:311 NORFOLK ST
Mailing Address - Street 2:
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-4202
Mailing Address - Country:US
Mailing Address - Phone:443-422-0383
Mailing Address - Fax:
Practice Address - Street 1:33 MAGOTHY BEACH RD STE 102-103
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-4413
Practice Address - Country:US
Practice Address - Phone:410-255-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-22
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MDC0007890363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant