Provider Demographics
NPI:1386609410
Name:HENRITZE, JOHN R (PA-C)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:R
Last Name:HENRITZE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2410 SUSANNAH ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1748
Mailing Address - Country:US
Mailing Address - Phone:423-282-9011
Mailing Address - Fax:423-282-0035
Practice Address - Street 1:340 STEELES RD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-9532
Practice Address - Country:US
Practice Address - Phone:423-282-9011
Practice Address - Fax:423-282-0035
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA0000001035363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPA0000001035OtherLICENSE
VA1386609410Medicaid
TN1517352Medicaid
TN6682290001Medicare NSC
TNPA0000001035OtherLICENSE