Basic Information
| Provider Information | |||||||||
| NPI: | 1225375736 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | BRADLEY | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 368 | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985070368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604918439 | ||||||||
| FaxNumber: | 3604916328 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 BROADWAY | ||||||||
| Address2: | 6TH FLOOR | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981225330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063862600 | ||||||||
| FaxNumber: | 2066221644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2013 | ||||||||
| LastUpdateDate: | 06/15/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA08230 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | PA60687300 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 315256301 | 05 | TX | MEDICAID |