Provider Demographics
NPI:1447416516
Name:HENDRICKSON, JOHANNA (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JOHANNA
Other - Middle Name:
Other - Last Name:HASTLER-ROJAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:220 CAMPUS BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-2896
Mailing Address - Country:US
Mailing Address - Phone:540-536-5100
Mailing Address - Fax:540-536-0235
Practice Address - Street 1:454 E MEDICAL WAY
Practice Address - Street 2:
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-1391
Practice Address - Country:US
Practice Address - Phone:435-657-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-29
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
VA0110007662363AS0400X
UT5317663-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT5421450001Medicare NSC
UT000066997Medicare PIN