Wijaya, Henderson Victor

Wijaya, Henderson Victor is an sole proprietor health care provider with primary practice located at 111050 Mount Belvedere Blvd , Fort Drum NY 13602. He recently has 3 registered licenses in different health care specialties including Technologists, Technicians & Other Technical Service Providers / Technician, Other, Physician Assistants & Advanced Practice Nursing Providers / Physician Assistant, Physician Assistants & Advanced Practice Nursing Providers / Medical. Physician Assistants & Advanced Practice Nursing Providers / Medical is his primary health care specialty. Wijaya, Henderson Victor can be contacted via phone (315) 772-6976.

Contact Information

Primary practice address
111050 Mount Belvedere Blvd Fort Drum NY 13602
Phone: (315) 772-6976
Fax:
Website:
Map and Directions

Health care specialties

SpecialtyCodeLicense #State
Technologists, Technicians & Other Technical Service Providers / Technician, Other 247200000X
Physician Assistants & Advanced Practice Nursing Providers / Physician Assistant 363A00000X 1178843
Physician Assistants & Advanced Practice Nursing Providers / Medical 363AM0700X 028353 New York

Profile Details

NPI number 1326418823
LBN Legal business name Wijaya, Henderson Victor
Credentials Physician's Assistant Certified (PA-C)
Entity Individual
Sole proprietor 1 Yes
Enumeration date Sep 28th, 2015
Last updated Sep 30th, 2023 - about 3 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1326418823 NPPES
Other 1178843 NCCPA ID

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