Basic Information
| Provider Information | |||||||||
| NPI: | 1568989846 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENDERSHOT | ||||||||
| FirstName: | NICHOLAS | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5154 FULTON DR NW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447182365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304927950 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1320 MERCY DR NW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447082614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304891000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2017 | ||||||||
| LastUpdateDate: | 04/18/2018 | ||||||||
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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 | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.