MEDICARE: MR. JOHN R. HENRITZE PA-C

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	PA0000001035	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PA0000001035	OTHER	TN	LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386609410
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN R. HENRITZE PA-C

Provider Business Mailing Address
First Line	:	2410 SUSANNAH ST
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37601-1748
Country	:	US
Telephone Number	:	423-282-9011
Fax Number	:	423-282-0035

Provider Business Practice Location Address
First Line	:	340 STEELES RD
Second Line	:
City	:	BRISTOL
State	:	TN
Zip	:	37620-9532
Country	:	US
Telephone Number	:	423-282-9011
Fax Number	:	423-282-0035

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

Provider Enumeration Date	:	04/20/2006
Last Update Date	:	08/27/2021

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