Provider Demographics
NPI:1154459709
Name:HENRY, ISAAC NATHANIEL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ISAAC
Middle Name:NATHANIEL
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 1:32206 ONE HALF LAKEVIEW TERRACE
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-0534
Mailing Address - Country:US
Mailing Address - Phone:951-445-6160
Mailing Address - Fax:
Practice Address - Street 1:1001 S STATE ST
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-7186
Practice Address - Country:US
Practice Address - Phone:951-925-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19039363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant