Provider Demographics
NPI:1710076112
Name:HENDRICKS, EDYTH Z (PA)
Entity Type:Individual
Prefix:
First Name:EDYTH
Middle Name:Z
Last Name:HENDRICKS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:EDYTH
Other - Middle Name:Z
Other - Last Name:LUDWIGSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14780 W. MOUNTAIN VIEW BLVD.
Mailing Address - Street 2:SUITE 110
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-7280
Mailing Address - Country:US
Mailing Address - Phone:480-415-1534
Mailing Address - Fax:
Practice Address - Street 1:14780 W. MOUNTAIN VIEW BLVD.
Practice Address - Street 2:SUITE 110
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-7280
Practice Address - Country:US
Practice Address - Phone:623-374-7774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3188363A00000X
AZ31-88363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP55819Medicare UPIN
TX87N386Medicare ID - Type Unspecified