Provider Demographics
NPI:1831647197
Name:HENSLEY, NICHOLAS (MPAS, PA-C)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:
Last Name:HENSLEY
Suffix:
Gender:M
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3155 CHANNING WAY STE B
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7534
Mailing Address - Country:US
Mailing Address - Phone:208-535-4800
Mailing Address - Fax:208-535-4807
Practice Address - Street 1:3155 CHANNING WAY STE B
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7534
Practice Address - Country:US
Practice Address - Phone:208-535-4800
Practice Address - Fax:208-535-4807
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-15
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1410363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002786100Medicaid
IDG20851Medicare UPIN
ID002786100Medicaid