Provider Demographics
NPI:1023092822
Name:HENDERSON, MARGOT D (PA-C)
Entity type:Individual
Prefix:
First Name:MARGOT
Middle Name:D
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 1:3900 STOCKTON HILL RD STE B368
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3029
Mailing Address - Country:US
Mailing Address - Phone:928-681-1234
Mailing Address - Fax:928-681-1811
Practice Address - Street 1:1755 AIRWAY AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3620
Practice Address - Country:US
Practice Address - Phone:928-681-1234
Practice Address - Fax:928-681-1811
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2798363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ827149Medicaid
AZP00256908OtherRAILROAD MEDICARE
P25453Medicare UPIN
AZZ104424Medicare PIN