Basic Information
| Provider Information | |||||||||
| NPI: | 1205498656 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | ALYSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 228 E HILLSIDE AVE | ||||||||
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| City: | FERGUS FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565371291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018661719 | ||||||||
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| Practice Location | |||||||||
| Address1: | 712 S CASCADE ST | ||||||||
| Address2: | |||||||||
| City: | FERGUS FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565372913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187368000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2019 | ||||||||
| LastUpdateDate: | 07/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 13057 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.