Provider Demographics
NPI:1245429414
Name:HENDRICKSON, MINDY STADLER (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MINDY
Middle Name:STADLER
Last Name:HENDRICKSON
Suffix:
Gender:F
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 1:15215 S 48TH ST
Mailing Address - Street 2:SUITE 120
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-9142
Mailing Address - Country:US
Mailing Address - Phone:480-706-6580
Mailing Address - Fax:480-706-8157
Practice Address - Street 1:15215 S 48TH ST
Practice Address - Street 2:SUITE 120
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-9142
Practice Address - Country:US
Practice Address - Phone:480-706-6580
Practice Address - Fax:480-706-8157
Is Sole Proprietor?:No
Enumeration Date:2007-10-23
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3725363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ171485Medicare PIN