Healthcare Provider Details

I. General information

NPI: 1447416516
Provider Name (Legal Business Name): JOHANNA HENDRICKSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JOHANNA HASTLER-ROJAS

II. Dates (important events)

Enumeration Date: 07/29/2008
Last Update Date: 08/12/2021
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

454 E MEDICAL WAY
HEBER CITY UT
84032-1391
US

IV. Provider business mailing address

220 CAMPUS BLVD STE 100
WINCHESTER VA
22601-2896
US

V. Phone/Fax

Practice location:
  • Phone: 435-657-4400
  • Fax:
Mailing address:
  • Phone: 540-536-5100
  • Fax: 540-536-0235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5317663-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0110007662
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: