Provider Demographics
NPI:1336605237
Name:HENSON, MACY L (PA-C)
Entity Type:Individual
Prefix:
First Name:MACY
Middle Name:L
Last Name:HENSON
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 1:305 W JACKSON ST STE 200
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-1474
Mailing Address - Country:US
Mailing Address - Phone:618-536-6621
Mailing Address - Fax:618-453-1102
Practice Address - Street 1:305 W JACKSON ST STE 200
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1474
Practice Address - Country:US
Practice Address - Phone:618-536-6621
Practice Address - Fax:618-453-1102
Is Sole Proprietor?:No
Enumeration Date:2019-02-15
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006790363A00000X
IL085-006790363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant