Healthcare Provider Details

I. General information

NPI: 1558523951
Provider Name (Legal Business Name): MICHAEL JOHN HENDERSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 05/19/2023
Certification Date: 05/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13670 WALSINGHAM RD
LARGO FL
33774-3532
US

IV. Provider business mailing address

13670 WALSINGHAM RD
LARGO FL
33774-3532
US

V. Phone/Fax

Practice location:
  • Phone: 727-315-6974
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9113306
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: