Active NPI
Randolph Hayes Henderson, PHYSICIAN ASSISTANT
- Physician Assistant
- Jackson, MS
National Provider Identifier
1366530545
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physician Assistant
- License
- PA001
- Practice address
- 1500 E Woodrow Wilson Drive
G V Montgomery Department of Veterans Affairs
Jackson, MS 39216-5199 - Phone
- (601) 362-4471
- Fax
- (601) 364-1325
- NPI assigned
- Oct 11, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | PA001 | MS | Primary |
Addresses
Primary practice location
1500 E Woodrow Wilson Drive
G V Montgomery Department of Veterans Affairs
Jackson, MS 39216-5199
Mailing address
4223 Adams Station Road
Edwards, MS 39066
Phone (601) 885-2022
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PA001 | MS | MD | Physician Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1160524800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1184112000000",
"number": "1366530545",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4223 ADAMS STATION ROAD",
"city": "EDWARDS",
"state": "MS",
"postal_code": "39066",
"telephone_number": "601-885-2022",
"fax_number": "601-956-3468"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1500 E WOODROW WILSON DRIVE",
"address_2": "G V MONTGOMERY DEPARTMENT OF VETERANS AFFAIRS",
"city": "JACKSON",
"state": "MS",
"postal_code": "392165199",
"telephone_number": "601-362-4471",
"fax_number": "601-364-1325"
}
],
"practiceLocations": [],
"basic": {
"last_name": "HENDERSON",
"first_name": "RANDOLPH",
"middle_name": "HAYES",
"name_prefix": "Mr.",
"credential": "PHYSICIAN ASSISTANT",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-10-11",
"last_updated": "2007-07-11",
"status": "A"
},
"taxonomies": [
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "MS",
"license": "PA001",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Jackson, MS
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 11, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.