Provider Demographics
NPI: | 1033185699 |
---|---|
Name: | HENDRICKS, JONATHAN CLEON (PA-C) |
Entity Type: | Individual |
Prefix: | MR |
First Name: | JONATHAN |
Middle Name: | CLEON |
Last Name: | HENDRICKS |
Suffix: | |
Gender: | M |
Credentials: | PA-C |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | P.O. BOX 151368 |
Mailing Address - Street 2: | CAPE CORAL EMERGENCY PHYSICIANS |
Mailing Address - City: | CAPE CORAL |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33915-1368 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 239-424-3513 |
Mailing Address - Fax: | 239-424-4039 |
Practice Address - Street 1: | 636 DEL PRADO BOULEVARD |
Practice Address - Street 2: | |
Practice Address - City: | CAPE CORAL |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33990-2695 |
Practice Address - Country: | US |
Practice Address - Phone: | 239-424-2222 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-02-24 |
Last Update Date: | 2011-11-29 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | PA9101920 | 363A00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 291231700 | Medicaid | |
FL | E6929 | Medicare PIN | |
FL | 291231700 | Medicaid | |
FL | P02525 | Medicare UPIN | |
FL | 970028146 | Medicare PIN |