Basic Information
| Provider Information | |||||||||
| NPI: | 1972052777 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | MEAGAN | ||||||||
| MiddleName: | LAVIN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FLODEEN | ||||||||
| OtherFirstName: | MEAGAN | ||||||||
| OtherMiddleName: | LAVIN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 126 6TH AVE SW | ||||||||
| Address2: | |||||||||
| City: | RONAN | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598642600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 126 6TH AVE SW | ||||||||
| Address2: | |||||||||
| City: | RONAN | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598642600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4066763600 | ||||||||
| FaxNumber: | 4066763738 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2016 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MED-PAC-LIC-51495 | MT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.