Provider Demographics
NPI:1265440309
Name:HENDERSON, PATRICIA LEIGH (PA-C)
Entity type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:LEIGH
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 1:3600 SW 93RD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-2815
Mailing Address - Country:US
Mailing Address - Phone:503-297-2649
Mailing Address - Fax:
Practice Address - Street 1:3600 SW 93RD AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-2815
Practice Address - Country:US
Practice Address - Phone:503-860-0619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00508363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORS18479Medicare UPIN