Healthcare Provider Details

I. General information

NPI: 1407258957
Provider Name (Legal Business Name): MARTIN J. HENDRICKS PA-C, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2014
Last Update Date: 11/08/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 PORT OF TACOMA RD
TACOMA WA
98421-3707
US

IV. Provider business mailing address

1930 PORT OF TACOMA RD
TACOMA WA
98421-3707
US

V. Phone/Fax

Practice location:
  • Phone: 253-274-5521
  • Fax: 253-274-5525
Mailing address:
  • Phone: 253-274-5521
  • Fax: 253-274-5525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60623356
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberA160075492
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: