Provider Demographics
NPI:1497083455
Name:HENEGAN, DUSTIN D (PA)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:D
Last Name:HENEGAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 CAMPUS CIR
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:PA
Mailing Address - Zip Code:16148-7901
Mailing Address - Country:US
Mailing Address - Phone:724-346-2677
Mailing Address - Fax:724-346-2825
Practice Address - Street 1:1005 CAMPUS CIR
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:PA
Practice Address - Zip Code:16148-7901
Practice Address - Country:US
Practice Address - Phone:724-346-2677
Practice Address - Fax:724-346-2825
Is Sole Proprietor?:No
Enumeration Date:2009-12-02
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054170363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical