Provider Demographics
NPI:1528021896
Name:HENDRICK, JOHN HAMPTON JR (PAC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:HAMPTON
Last Name:HENDRICK
Suffix:JR
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2180 HENRY TECKLENBURG DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-5798
Mailing Address - Country:US
Mailing Address - Phone:438-556-8886
Mailing Address - Fax:843-556-8850
Practice Address - Street 1:2180 HENRY TECKLENBURG DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414
Practice Address - Country:US
Practice Address - Phone:843-556-8886
Practice Address - Fax:843-556-8850
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCPA709363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P01048436OtherRR MEDICARE
NC173ETOtherBLUE CROSS
NC5813AMedicare PIN