Healthcare Provider Details

I. General information

NPI: 1861768103
Provider Name (Legal Business Name): ANDREW HENDRICKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2012
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10901 E 48TH ST
TULSA OK
74146-5830
US

IV. Provider business mailing address

10901 E 48TH ST
TULSA OK
74146-5830
US

V. Phone/Fax

Practice location:
  • Phone: 918-749-8765
  • Fax: 918-392-2155
Mailing address:
  • Phone: 918-749-8765
  • Fax: 918-392-2155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number107087
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number56913
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number29125
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number56913
License Number StateMN
# 5
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number29125
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: