Provider Demographics
NPI:1801525241
Name:HENNESSY, JAMES (PA-C)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:
Last Name:HENNESSY
Suffix:
Gender:M
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 1:907 KEMPER DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-3708
Mailing Address - Country:US
Mailing Address - Phone:619-905-6330
Mailing Address - Fax:
Practice Address - Street 1:8705 E MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85257-3909
Practice Address - Country:US
Practice Address - Phone:480-882-4545
Practice Address - Fax:480-405-8929
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-09
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
AZ9186363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ163742Medicaid