Provider Demographics
NPI:1407258957
Name:HENDRICKS, MARTIN J (PA-C, ATC)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:J
Last Name:HENDRICKS
Suffix:
Gender:M
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 PORT OF TACOMA RD
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98421-3707
Mailing Address - Country:US
Mailing Address - Phone:253-274-5521
Mailing Address - Fax:253-274-5525
Practice Address - Street 1:1930 PORT OF TACOMA RD
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98421-3707
Practice Address - Country:US
Practice Address - Phone:253-274-5521
Practice Address - Fax:253-274-5525
Is Sole Proprietor?:No
Enumeration Date:2014-09-16
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAA1600754922255A2300X, 2255A2300X
WAPA60623356363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8954591Medicare PIN