Provider Demographics
NPI:1700855319
Name:MCHENRY, MICHAEL P (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
Last Name:MCHENRY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 W WACKERLY ST
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-4710
Mailing Address - Country:US
Mailing Address - Phone:989-631-9515
Mailing Address - Fax:989-839-8817
Practice Address - Street 1:555 W WACKERLY ST
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-4710
Practice Address - Country:US
Practice Address - Phone:989-631-9515
Practice Address - Fax:989-839-8817
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001165363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
R66460Medicare UPIN