Healthcare Provider Details

I. General information

NPI: 1023991346
Provider Name (Legal Business Name): GINA HENDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2025
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 COMMERCE DR STE 2000
WOODBURY MN
55125-4919
US

IV. Provider business mailing address

710 COMMERCE DR STE 200
WOODBURY MN
55125-4925
US

V. Phone/Fax

Practice location:
  • Phone: 414-288-5688
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: