Provider Demographics
NPI:1821639386
Name:HENRY, SAMUEL ETHAN (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ETHAN
Last Name:HENRY
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 1:2309 MEADOW VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-4913
Mailing Address - Country:US
Mailing Address - Phone:260-494-6735
Mailing Address - Fax:
Practice Address - Street 1:17273 OH 104
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601
Practice Address - Country:US
Practice Address - Phone:740-773-1141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant