Provider Demographics
NPI:1336652833
Name:HENDERSON, ALYSSA ILG (PA-C)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:ILG
Last Name:HENDERSON
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 1:3131 TURTLE CREEK BLVD STE 600
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-5435
Mailing Address - Country:US
Mailing Address - Phone:972-400-2866
Mailing Address - Fax:
Practice Address - Street 1:3131 TURTLE CREEK BLVD STE 600
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-5435
Practice Address - Country:US
Practice Address - Phone:972-400-2866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-07
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8588363A00000X
TXPA13008363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant