Basic Information
| Provider Information | |||||||||
| NPI: | 1669005369 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENSON | ||||||||
| FirstName: | REBECCA | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19305 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282199305 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 10660 PARK RD | ||||||||
| Address2: | STE 3100 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282108413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046678750 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2020 | ||||||||
| LastUpdateDate: | 11/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-09467 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 3537 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.