Provider Demographics
NPI:1225375736
Name:HENDERSON, WILLIAM BRADLEY (PA-C)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:BRADLEY
Last Name:HENDERSON
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 1:1651 W ROSEDALE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-7437
Mailing Address - Country:US
Mailing Address - Phone:817-930-2030
Mailing Address - Fax:817-930-2031
Practice Address - Street 1:1651 W ROSEDALE ST STE 100
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-7437
Practice Address - Country:US
Practice Address - Phone:817-930-2030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-04
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08230363AS0400X
WAPA60687300363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX315256301Medicaid
TX341217YKPWMedicare PIN