Provider Demographics
NPI:1801971676
Name:HENDERSON, EDDIE MICHAEL (PA-C)
Entity type:Individual
Prefix:MR
First Name:EDDIE
Middle Name:MICHAEL
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:MR
Other - First Name:MICHAEL
Other - Middle Name:
Other - Last Name:HENDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:101 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:BURNET
Mailing Address - State:TX
Mailing Address - Zip Code:78611-3101
Mailing Address - Country:US
Mailing Address - Phone:512-756-7510
Mailing Address - Fax:
Practice Address - Street 1:101 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:BURNET
Practice Address - State:TX
Practice Address - Zip Code:78611-3101
Practice Address - Country:US
Practice Address - Phone:512-756-7510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2012-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03311363AM0700X
NMNM2008-0046363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM57551251Medicaid
NM57551251Medicaid