Provider Demographics
NPI:1538877071
Name:HENDRICKSON, GORDON W (PA)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:W
Last Name:HENDRICKSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1338
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-7785
Mailing Address - Country:US
Mailing Address - Phone:360-423-0390
Mailing Address - Fax:360-577-3865
Practice Address - Street 1:1706 WASHINGTON WAY
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2952
Practice Address - Country:US
Practice Address - Phone:604-239-5803
Practice Address - Fax:360-423-6230
Is Sole Proprietor?:No
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAPA61369633363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant