Provider Demographics
NPI:1497301915
Name:HENSON, STEVAN KAI (PA-C)
Entity Type:Individual
Prefix:
First Name:STEVAN
Middle Name:KAI
Last Name:HENSON
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 1:1060 E COUNTY LINE RD STE 6
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-1937
Mailing Address - Country:US
Mailing Address - Phone:601-438-2678
Mailing Address - Fax:
Practice Address - Street 1:1060 E COUNTY LINE RD STE 6
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-1937
Practice Address - Country:US
Practice Address - Phone:601-438-2678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-12
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MSPA00520363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program