Healthcare Provider Details

I. General information

NPI: 1982680021
Provider Name (Legal Business Name): EDWARD HENDRIKSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 11/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 2ND ST
FORT LUPTON CO
80621-1745
US

IV. Provider business mailing address

203 S ROLLIE AVE
FORT LUPTON CO
80621-1508
US

V. Phone/Fax

Practice location:
  • Phone: 303-857-2771
  • Fax: 720-322-9434
Mailing address:
  • Phone: 303-286-4560
  • Fax: 303-286-4589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0000431
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: