Basic Information
| Provider Information | |||||||||
| NPI: | 1790292332 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDRICKSON | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | STANLEY | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 190 | ||||||||
| Address2: | |||||||||
| City: | SAINT STEPHENS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825240190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078560470 | ||||||||
| FaxNumber: | 3074634254 | ||||||||
| Practice Location | |||||||||
| Address1: | 24 GREAT PLAINS RD | ||||||||
| Address2: | |||||||||
| City: | ARAPAHOE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825109144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078560470 | ||||||||
| FaxNumber: | 3074634254 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2018 | ||||||||
| LastUpdateDate: | 01/04/2018 | ||||||||
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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 | 172V00000X | WY | Y | Other Service Providers | Community Health Worker |
No ID Information.