Provider Demographics
NPI:1407872401
Name:HENDERSHOT, JON PAUL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:PAUL
Last Name:HENDERSHOT
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 1:4601 PARK RD
Mailing Address - Street 2:STE 300
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-2290
Mailing Address - Country:US
Mailing Address - Phone:704-323-2090
Mailing Address - Fax:
Practice Address - Street 1:2001 VAIL AVE STE 200A
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1222
Practice Address - Country:US
Practice Address - Phone:704-323-2564
Practice Address - Fax:732-840-2088
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06586363A00000X
NJ25MP00137500363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q39808Medicare UPIN
089687M09Medicare PIN
NJ089687T2BMedicare ID - Type Unspecified