Provider Demographics
NPI:1477656692
Name:HENKE, VIRGINIA DETERMAN (PA-MPAS)
Entity Type:Individual
Prefix:MRS
First Name:VIRGINIA
Middle Name:DETERMAN
Last Name:HENKE
Suffix:
Gender:F
Credentials:PA-MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 S HEMLOCK ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-3800
Mailing Address - Country:US
Mailing Address - Phone:906-779-4270
Mailing Address - Fax:906-779-4276
Practice Address - Street 1:1115 S HEMLOCK ST
Practice Address - Street 2:SUITE 6
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-3800
Practice Address - Country:US
Practice Address - Phone:906-779-4270
Practice Address - Fax:906-779-4276
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001688363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant