Provider Demographics
NPI:1477567279
Name:HENDERSON, GLENN H (PA)
Entity type:Individual
Prefix:MR
First Name:GLENN
Middle Name:H
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1300 MICCOSUKEE RD
Mailing Address - Street 2:HOSPITALIST GROUP
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5054
Mailing Address - Country:US
Mailing Address - Phone:850-431-4997
Mailing Address - Fax:850-431-6315
Practice Address - Street 1:1300 MICCOSUKEE RD
Practice Address - Street 2:HOSPITALIST GROUP
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5054
Practice Address - Country:US
Practice Address - Phone:850-431-4997
Practice Address - Fax:850-431-6315
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA2228363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2907232Medicaid
FL2907232Medicaid