Provider Demographics
NPI:1326553256
Name:HENDERSHOT, CHESTER ALAN JR (MHA,MHS, PA-C)
Entity type:Individual
Prefix:MR
First Name:CHESTER
Middle Name:ALAN
Last Name:HENDERSHOT
Suffix:JR
Gender:M
Credentials:MHA,MHS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3108 NW 184TH ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-9650
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:709 N CZECH HALL RD
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-7897
Practice Address - Country:US
Practice Address - Phone:405-949-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-14
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2821363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1149304OtherNCCPA
OKPA2821OtherOKLAHOMA STATE MEDICAL BOARD OF LICENSURE AND SUPERVISION