Healthcare Provider Details

I. General information

NPI: 1134200223
Provider Name (Legal Business Name): PAUL C HENSON P.A.C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 05/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

998 S HIGHWAY 25 W SUITE 1
WILLIAMSBURG KY
40769-1692
US

IV. Provider business mailing address

998 S HIGHWAY 25 W STE 1
WILLIAMSBURG KY
40769-1692
US

V. Phone/Fax

Practice location:
  • Phone: 606-549-1183
  • Fax: 606-549-4900
Mailing address:
  • Phone: 606-549-1183
  • Fax: 606-549-4900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA071
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA0000000153
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: