Healthcare Provider Details

I. General information

NPI: 1053846170
Provider Name (Legal Business Name): PATRICK MICHAEL HENDRICKSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2017
Last Update Date: 04/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W HUTCHINGS ST # 100
WINTERSET IA
50273-2109
US

IV. Provider business mailing address

300 W HUTCHINGS ST # 100
WINTERSET IA
50273-2109
US

V. Phone/Fax

Practice location:
  • Phone: 515-462-2373
  • Fax:
Mailing address:
  • Phone: 515-462-2373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number087169
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: