Provider Demographics
NPI:1255197018
Name:HENDRICKS, MIKENZIE (PA-C)
Entity type:Individual
Prefix:
First Name:MIKENZIE
Middle Name:
Last Name:HENDRICKS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MIKENZIE
Other - Middle Name:
Other - Last Name:PARKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:948 W VAHE ST
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-8416
Mailing Address - Country:US
Mailing Address - Phone:801-859-5939
Mailing Address - Fax:
Practice Address - Street 1:228 W 200 S
Practice Address - Street 2:
Practice Address - City:KAMAS
Practice Address - State:UT
Practice Address - Zip Code:84036-9010
Practice Address - Country:US
Practice Address - Phone:435-783-4385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-27
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13416827-1206207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine