Individual
BENJAMIN RANDERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
10400 75TH ST, KENOSHA, WI 53142-7884
(262) 948-5600
Mailing address
PO BOX 735044, CHICAGO, IL 60673-5044
(262) 948-5600
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
7503
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100250637
—
WI
Enumeration date
02/21/2023
Last updated
10/26/2023
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