Healthcare Provider Details

I. General information

NPI: 1922080183
Provider Name (Legal Business Name): EDMOND WAYNE HENDRICKSON PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 12/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 NAT WASHINGTON WAY
EPHRATA WA
98823-1982
US

IV. Provider business mailing address

200 NAT WASHINGTON WAY
EPHRATA WA
98823-1982
US

V. Phone/Fax

Practice location:
  • Phone: 509-754-4631
  • Fax: 509-754-4809
Mailing address:
  • Phone: 509-754-4631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA10000409
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: