Provider Demographics
NPI:1164487146
Name:HENDERSON, REINO ARNOLD (PA-C)
Entity Type:Individual
Prefix:MR
First Name:REINO
Middle Name:ARNOLD
Last Name:HENDERSON
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 1:10301 KANIS RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6205
Mailing Address - Country:US
Mailing Address - Phone:501-604-6900
Mailing Address - Fax:501-604-3220
Practice Address - Street 1:10301 KANIS RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6205
Practice Address - Country:US
Practice Address - Phone:501-604-6900
Practice Address - Fax:501-604-3220
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4995111N00000X
ARPA252363AM0700X, 363AS0400X
AZ2904363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No111N00000XChiropractic ProvidersChiropractor
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR386576YNV5Medicare PIN
AR1164487146Medicare PIN