MEDICARE: MRS. ELIZABETH JANE HENDRICKS PAC

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	10000483A	IN

General Provider Information

NPI Number	:	1659314524
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ELIZABETH JANE HENDRICKS PAC

Provider Business Mailing Address
First Line	:	3717 MAPLECREST RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-8424
Country	:	US
Telephone Number	:	260-486-7334
Fax Number	:	260-486-6447

Provider Business Practice Location Address
First Line	:	3717 MAPLECREST RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-8424
Country	:	US
Telephone Number	:	260-486-7334
Fax Number	:	260-486-6447

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

Provider Enumeration Date	:	06/14/2006
Last Update Date	:	03/15/2011

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