Provider Demographics
NPI:1114464906
Name:HENRY, MICHAEL THOMAS (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:HENRY
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 1:115 BOWATER CT
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-5528
Mailing Address - Country:US
Mailing Address - Phone:631-926-9973
Mailing Address - Fax:
Practice Address - Street 1:701 E MARSHALL ST
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-4412
Practice Address - Country:US
Practice Address - Phone:610-431-5550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-31
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA058830363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant