Healthcare Provider Details

I. General information

NPI: 1205196805
Provider Name (Legal Business Name): MICHAEL KYLE HENDRICKS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: KYLE HENDRICKS PA-C

II. Dates (important events)

Enumeration Date: 05/17/2012
Last Update Date: 06/16/2023
Certification Date: 06/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 JACKSON ST
MONROE LA
71201-7407
US

IV. Provider business mailing address

204 KNOLL CREEK CIR
WEST MONROE LA
71291-4773
US

V. Phone/Fax

Practice location:
  • Phone: 318-966-2397
  • Fax:
Mailing address:
  • Phone: 318-366-4367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: