Provider Demographics
NPI:1720382922
Name:HENDERSON, GERALD MARK (PA-C)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:MARK
Last Name:HENDERSON
Suffix:
Gender:M
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 1:104 N DAVIS ST
Mailing Address - Street 2:
Mailing Address - City:BELGRADE
Mailing Address - State:MT
Mailing Address - Zip Code:59714-3817
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:320 ALPENGLOW LN
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:MT
Practice Address - Zip Code:59047-8506
Practice Address - Country:US
Practice Address - Phone:406-222-3541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-03
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT557363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical