Healthcare Provider Details

I. General information

NPI: 1134608201
Provider Name (Legal Business Name): GREGORY MICHAEL HENDERSHOT CAA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2018
Last Update Date: 09/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 W HIBISCUS BLVD STE 215
MELBOURNE FL
32901-2627
US

IV. Provider business mailing address

2448 CORAL RIDGE CIR
MELBOURNE FL
32935-3629
US

V. Phone/Fax

Practice location:
  • Phone: 321-837-3820
  • Fax: 321-837-3654
Mailing address:
  • Phone: 321-412-0475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License NumberAA465
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: