Provider Demographics
NPI:1780141770
Name:HENDERSON, KRISTIN LEE (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:LEE
Last Name:HENDERSON
Suffix:
Gender:F
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 1:2100 STANTONSBURG RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-2818
Mailing Address - Country:US
Mailing Address - Phone:252-537-5631
Mailing Address - Fax:252-537-7198
Practice Address - Street 1:2100 STANTONSBURG RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-2818
Practice Address - Country:US
Practice Address - Phone:252-537-5631
Practice Address - Fax:252-537-7198
Is Sole Proprietor?:No
Enumeration Date:2019-02-26
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-08880363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1780141770Medicaid
NC0010-08880OtherNC MEDICAL LICENSE