Provider Demographics
NPI:1992723530
Name:HENDRICKS, LARRY ALAN (PA-C)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:ALAN
Last Name:HENDRICKS
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 1:520 CHAUTAUQUA BLVD
Mailing Address - Street 2:
Mailing Address - City:VALLEY CITY
Mailing Address - State:ND
Mailing Address - Zip Code:58072-3145
Mailing Address - Country:US
Mailing Address - Phone:701-845-6000
Mailing Address - Fax:701-845-6150
Practice Address - Street 1:520 CHAUTAUQUA BLVD
Practice Address - Street 2:
Practice Address - City:VALLEY CITY
Practice Address - State:ND
Practice Address - Zip Code:58072-3145
Practice Address - Country:US
Practice Address - Phone:701-845-6000
Practice Address - Fax:701-845-6150
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0123363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
R02396Medicare UPIN