Healthcare Provider Details

I. General information

NPI: 1558315515
Provider Name (Legal Business Name): DEBORAH L. HENDERSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 03/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72780 COUNTRY CLUB DR BLDG B 203
RANCHO MIRAGE CA
92270-4126
US

IV. Provider business mailing address

72780 COUNTRY CLUB DR BLDG B 203
RANCHO MIRAGE CA
92270-4126
US

V. Phone/Fax

Practice location:
  • Phone: 760-674-3847
  • Fax: 760-674-3845
Mailing address:
  • Phone: 760-674-3847
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA17812
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: