Provider Demographics
NPI:1740675040
Name:HENDRICKSON, BRYAN KENT (MD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:KENT
Last Name:HENDRICKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 NEENAH CTR
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-3070
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3925 N GATEWAY DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-7863
Practice Address - Country:US
Practice Address - Phone:920-454-8401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-02
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10094314-1205207Q00000X
WI69375-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine