Provider Demographics
NPI:1558315515
Name:HENDERSON, DEBORAH L (PA-C)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:L
Last Name:HENDERSON
Suffix:
Gender:F
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 1:72780 COUNTRY CLUB DR
Mailing Address - Street 2:BLDG B 203
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-4126
Mailing Address - Country:US
Mailing Address - Phone:760-674-3847
Mailing Address - Fax:
Practice Address - Street 1:72780 COUNTRY CLUB DR
Practice Address - Street 2:BLDG B 203
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-4126
Practice Address - Country:US
Practice Address - Phone:760-674-3847
Practice Address - Fax:760-674-3845
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17812363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00246545OtherGOOD SAMARITAN RAILROAD
CAPA17812Medicaid
CAQ38897Medicare UPIN
CAWPA17812AMedicare Oscar/Certification
CAP00246545OtherGOOD SAMARITAN RAILROAD