Provider Demographics
NPI:1104845924
Name:HENRY, STEPHEN S (CRNA)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:S
Last Name:HENRY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-446-5238
Mailing Address - Fax:740-441-8058
Practice Address - Street 1:100 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1560
Practice Address - Country:US
Practice Address - Phone:855-446-5937
Practice Address - Fax:740-441-8058
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.09873NA367500000X
WV59476367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2298731Medicaid
000000307864OtherANTHEM BCBS
WV1104845924Medicaid
500022235OtherRR MEDICARE
OH000000230049OtherOH MEDICAID UNISON
OHNP08691Medicare PIN