Provider Demographics
NPI:1275646317
Name:HENDERSON, PAULA C (MD)
Entity type:Individual
Prefix:
First Name:PAULA
Middle Name:C
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 N SAN JACINTO ST
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-3118
Mailing Address - Country:US
Mailing Address - Phone:951-929-6003
Mailing Address - Fax:888-696-2618
Practice Address - Street 1:391 N SAN JACINTO ST
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-3118
Practice Address - Country:US
Practice Address - Phone:951-929-6003
Practice Address - Fax:888-696-2618
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66348207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A663480Medicaid
CAWA66348BMedicare PIN
CAH34129Medicare UPIN
CAWA66348AMedicare PIN