Provider Demographics
NPI:1063663102
Name:HENDERSON, ERIN MARIE (MD)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:MARIE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:MARIE
Other - Last Name:BRANDL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:61 S GOULD ST
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-6304
Mailing Address - Country:US
Mailing Address - Phone:307-675-2690
Mailing Address - Fax:307-675-2691
Practice Address - Street 1:61 S GOULD ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-6304
Practice Address - Country:US
Practice Address - Phone:307-675-2690
Practice Address - Fax:307-675-2691
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO50126207R00000X
WYTL7953207R00000X
WY16319A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO46054561Medicaid
CO46054561Medicaid