Provider Demographics
NPI:1366530545
Name:HENDERSON, RANDOLPH HAYES (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MR
First Name:RANDOLPH
Middle Name:HAYES
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
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Mailing Address - Street 1:4223 ADAMS STATION ROAD
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:MS
Mailing Address - Zip Code:39066
Mailing Address - Country:US
Mailing Address - Phone:601-885-2022
Mailing Address - Fax:601-956-3468
Practice Address - Street 1:1500 E WOODROW WILSON DRIVE
Practice Address - Street 2:G V MONTGOMERY DEPARTMENT OF VETERANS AFFAIRS
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5199
Practice Address - Country:US
Practice Address - Phone:601-362-4471
Practice Address - Fax:601-364-1325
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MSPA001363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant