Healthcare Provider Details

I. General information

NPI: 1407872401
Provider Name (Legal Business Name): JON PAUL HENDERSHOT PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 01/06/2023
Certification Date: 01/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 VAIL AVE STE 200A
CHARLOTTE NC
28207-1222
US

IV. Provider business mailing address

4601 PARK RD STE 300
CHARLOTTE NC
28209-2290
US

V. Phone/Fax

Practice location:
  • Phone: 704-323-2564
  • Fax: 732-840-2088
Mailing address:
  • Phone: 704-323-2090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-06586
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: