Provider Demographics
NPI:1598720492
Name:HENDERSON, PATRICK EDWARD (DO)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:EDWARD
Last Name:HENDERSON
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 1:319 E PIONEER AVE
Mailing Address - Street 2:
Mailing Address - City:MONTESANO
Mailing Address - State:WA
Mailing Address - Zip Code:98563
Mailing Address - Country:US
Mailing Address - Phone:360-249-3300
Mailing Address - Fax:360-249-3444
Practice Address - Street 1:319 E PIONEER AVE
Practice Address - Street 2:
Practice Address - City:MONTESANO
Practice Address - State:WA
Practice Address - Zip Code:98563
Practice Address - Country:US
Practice Address - Phone:360-249-3300
Practice Address - Fax:360-249-3444
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31899207YS0123X
WAOP60414976207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ008647OtherSTATE LICENSE
CO01318997Medicaid
CO31899OtherSTATE LICENSE NUMBER
COE00741Medicare UPIN