Provider Demographics
NPI:1811550759
Name:HENDERSON, CASSANDRA LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:LYNN
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 1:2001 W ALVARADO RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85009-2830
Mailing Address - Country:US
Mailing Address - Phone:518-847-6522
Mailing Address - Fax:
Practice Address - Street 1:20401 N 73RD ST
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-4107
Practice Address - Country:US
Practice Address - Phone:480-556-0446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-16
Last Update Date:2020-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8178207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ8178OtherARIZONA REGULATORY BOARD OF PHYSICIAN ASSISTANTS
1176027OtherNCCPA