MEDICARE: JOHN EVERETT HENDRICKS JR. PHYSICIAN ASSISTANT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	10001247A/B	IN

General Provider Information

NPI Number	:	1154476976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN EVERETT HENDRICKS JR. PHYSICIAN ASSISTANT

Provider Business Mailing Address
First Line	:	5411 W 78TH ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46268-4150
Country	:	US
Telephone Number	:	317-876-6928
Fax Number	:	317-876-6931

Provider Business Practice Location Address
First Line	:	5411 W 78TH ST
Second Line	:	JOHNS HOPKINS UNIVERSITY/PEPSICO HEALTH & WELLNESS CTR
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46268-4150
Country	:	US
Telephone Number	:	317-876-6928
Fax Number	:	317-876-6931

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2007
Last Update Date	:	12/10/2012

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