Healthcare Provider Details

I. General information

NPI: 1174883292
Provider Name (Legal Business Name): CORY RYAN HENDERSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2012
Last Update Date: 08/15/2022
Certification Date: 08/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57950 LEAVENWORTH ST
MCCONNELL AFB KS
67221-3505
US

IV. Provider business mailing address

57950 LEAVENWORTH ST
MCCONNELL AFB KS
67221-3505
US

V. Phone/Fax

Practice location:
  • Phone: 316-759-5120
  • Fax: 316-759-6553
Mailing address:
  • Phone: 316-759-5120
  • Fax: 316-759-6553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: