Basic Information
Provider Information | |||||||||
NPI: | 1497907737 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HENSON | ||||||||
FirstName: | ANGELA | ||||||||
MiddleName: | H | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BLACK | ||||||||
OtherFirstName: | ANGELA | ||||||||
OtherMiddleName: | H | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 3412 OFFICE PARK DRIVE | ||||||||
Address2: |   | ||||||||
City: | MARION | ||||||||
State: | IL | ||||||||
PostalCode: | 62959 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6189930404 | ||||||||
FaxNumber: | 6189931717 | ||||||||
Practice Location | |||||||||
Address1: | 310 WEST ST. LOUIS STREET | ||||||||
Address2: |   | ||||||||
City: | WEST FRANKFORT | ||||||||
State: | IL | ||||||||
PostalCode: | 62896 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6189930404 | ||||||||
FaxNumber: | 6189931717 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/17/2008 | ||||||||
LastUpdateDate: | 05/22/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085003341 | IL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.