Healthcare Provider Details

I. General information

NPI: 1538877071
Provider Name (Legal Business Name): GORDON W HENDRICKSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2022
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

528 COFFEEN AVE
SHERIDAN WY
82801-5312
US

IV. Provider business mailing address

528 COFFEEN AVE
SHERIDAN WY
82801-5312
US

V. Phone/Fax

Practice location:
  • Phone: 307-683-7138
  • Fax:
Mailing address:
  • Phone: 307-683-7138
  • Fax: 307-655-8770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1447
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61369633
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: