Provider Demographics
NPI:1659314524
Name:HENDRICKS, ELIZABETH JANE (PAC)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:JANE
Last Name:HENDRICKS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MS
Other - First Name:ELIZABETH
Other - Middle Name:JANE
Other - Last Name:MCLAUGHLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3717 MAPLECREST RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-8424
Mailing Address - Country:US
Mailing Address - Phone:260-486-7334
Mailing Address - Fax:260-486-6447
Practice Address - Street 1:3717 MAPLECREST RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-8424
Practice Address - Country:US
Practice Address - Phone:260-486-7334
Practice Address - Fax:260-486-6447
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000483A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400036670Medicare PIN
INP24515Medicare UPIN