Provider Demographics
NPI:1497920078
Name:HUTTEMAN, HENRY RUSSELL (PA-C)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:RUSSELL
Last Name:HUTTEMAN
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 1:10720 N LOOP DR
Mailing Address - Street 2:STE A-6
Mailing Address - City:SOCORRO
Mailing Address - State:TX
Mailing Address - Zip Code:79927-4409
Mailing Address - Country:US
Mailing Address - Phone:915-858-0500
Mailing Address - Fax:
Practice Address - Street 1:10720 N LOOP DR
Practice Address - Street 2:STE A-6
Practice Address - City:SOCORRO
Practice Address - State:TX
Practice Address - Zip Code:79927-4409
Practice Address - Country:US
Practice Address - Phone:915-858-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04298363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant