Provider Demographics
NPI:1013017060
Name:HENNING, PHILLIP TROY (DO)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:TROY
Last Name:HENNING
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:1600 E JEFFERSON ST
Practice Address - Street 2:STE 300
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-5698
Practice Address - Country:US
Practice Address - Phone:425-498-2272
Practice Address - Fax:425-498-2334
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP000022232081S0010X
MI51010185062081S0010X, 208100000X
MN51136208100000X
MN103684208100000X
WAOL20000101208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN250000784Medicare PIN