Provider Demographics
NPI:1447530498
Name:HENDERSON, DEREK ALLEN (PA)
Entity type:Individual
Prefix:MR
First Name:DEREK
Middle Name:ALLEN
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:PO BOX 437
Mailing Address - Street 2:
Mailing Address - City:BUCHANAN
Mailing Address - State:MI
Mailing Address - Zip Code:49107-0437
Mailing Address - Country:US
Mailing Address - Phone:269-695-0262
Mailing Address - Fax:269-695-2590
Practice Address - Street 1:1045 E FRONT ST
Practice Address - Street 2:
Practice Address - City:BUCHANAN
Practice Address - State:MI
Practice Address - Zip Code:49107-8474
Practice Address - Country:US
Practice Address - Phone:269-695-5540
Practice Address - Fax:269-695-0412
Is Sole Proprietor?:No
Enumeration Date:2011-08-23
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601006108363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant