Provider Demographics
NPI:1104376904
Name:HENDERSON, MARIAH SWIECH (PA)
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:SWIECH
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 PROFESSORS ROW
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-5816
Mailing Address - Country:US
Mailing Address - Phone:617-627-7947
Mailing Address - Fax:
Practice Address - Street 1:124 PROFESSORS ROW
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-5816
Practice Address - Country:US
Practice Address - Phone:617-627-7947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-05
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA5908363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant