Healthcare Provider Details

I. General information

NPI: 1245429414
Provider Name (Legal Business Name): MINDY STADLER HENDRICKSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2007
Last Update Date: 12/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15215 S 48TH ST SUITE 120
PHOENIX AZ
85044-9142
US

IV. Provider business mailing address

15215 S 48TH ST SUITE 120
PHOENIX AZ
85044-9142
US

V. Phone/Fax

Practice location:
  • Phone: 480-706-6580
  • Fax: 480-706-8157
Mailing address:
  • Phone: 480-706-6580
  • Fax: 480-706-8157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3725
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: