Provider Demographics
NPI:1134200223
Name:HENSON, PAUL C (PAC)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:C
Last Name:HENSON
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 1:998 S HIGHWAY 25 W
Mailing Address - Street 2:STE 1
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40769-1692
Mailing Address - Country:US
Mailing Address - Phone:606-549-1183
Mailing Address - Fax:606-549-4900
Practice Address - Street 1:998 S HIGHWAY 25 W
Practice Address - Street 2:SUITE 1
Practice Address - City:WILLIAMSBURG
Practice Address - State:KY
Practice Address - Zip Code:40769-1692
Practice Address - Country:US
Practice Address - Phone:606-549-1183
Practice Address - Fax:606-549-4900
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA071363AM0700X
TNPA0000000153363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3677814Medicaid
KY9500025300Medicaid
TN3677814Medicare PIN
TN3677814Medicaid
KY329113Medicare PIN