Provider Demographics
NPI:1578787792
Name:HENDERSON, SAMUEL B (SA-C)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:B
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:SAMUEL
Other - Middle Name:B
Other - Last Name:HENDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:SA-C
Mailing Address - Street 1:5918 DEWDROP LANE
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109
Mailing Address - Country:US
Mailing Address - Phone:830-734-2689
Mailing Address - Fax:210-475-3995
Practice Address - Street 1:5918 DEWDROP LANE
Practice Address - Street 2:
Practice Address - City:CONVERSE
Practice Address - State:TX
Practice Address - Zip Code:78109
Practice Address - Country:US
Practice Address - Phone:830-734-2689
Practice Address - Fax:210-475-3995
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10-143246ZC0007X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Multi-Specialty