Provider Demographics
NPI:1689924581
Name:HERNDON, JAMES DATSON (PA-C)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:DATSON
Last Name:HERNDON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:69730 HIGHWAY 111 STE 109
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-2873
Mailing Address - Country:US
Mailing Address - Phone:206-852-8815
Mailing Address - Fax:
Practice Address - Street 1:69730 HIGHWAY 111 STE 109
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-2873
Practice Address - Country:US
Practice Address - Phone:760-778-6120
Practice Address - Fax:607-406-6077
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-18
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA156961363A00000X
CAPA16694363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant