Provider Demographics
NPI:1487264164
Name:HENDRICKSON, CAMERON CHARLES
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:CHARLES
Last Name:HENDRICKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 STEAMBOAT LN
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:MN
Mailing Address - Zip Code:55363-8723
Mailing Address - Country:US
Mailing Address - Phone:605-228-3624
Mailing Address - Fax:
Practice Address - Street 1:1406 6TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1900
Practice Address - Country:US
Practice Address - Phone:320-251-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-06
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2341314163W00000X
MN2516367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse