Provider Demographics
NPI:1205196805
Name:HENDRICKS, MICHAEL KYLE (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KYLE
Last Name:HENDRICKS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:KYLE
Other - Middle Name:
Other - Last Name:HENDRICKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:204 KNOLL CREEK CIR
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-4773
Mailing Address - Country:US
Mailing Address - Phone:318-366-4367
Mailing Address - Fax:
Practice Address - Street 1:309 JACKSON ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-7407
Practice Address - Country:US
Practice Address - Phone:318-966-2397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-17
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA225200000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant