Provider Demographics
NPI:1922080183
Name:HENDRICKSON, EDMOND WAYNE (PAC)
Entity Type:Individual
Prefix:
First Name:EDMOND
Middle Name:WAYNE
Last Name:HENDRICKSON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 NAT WASHINGTON WAY
Mailing Address - Street 2:
Mailing Address - City:EPHRATA
Mailing Address - State:WA
Mailing Address - Zip Code:98823-1982
Mailing Address - Country:US
Mailing Address - Phone:509-754-4631
Mailing Address - Fax:
Practice Address - Street 1:200 NAT WASHINGTON WAY
Practice Address - Street 2:
Practice Address - City:EPHRATA
Practice Address - State:WA
Practice Address - Zip Code:98823-1982
Practice Address - Country:US
Practice Address - Phone:509-754-4631
Practice Address - Fax:509-754-4809
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10000409363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P01961Medicare UPIN