Provider Demographics
NPI:1801864657
Name:HENDERSON, TODD RUSSELL (CRNA)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:RUSSELL
Last Name:HENDERSON
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 1:452 CHEYENNE CT
Mailing Address - Street 2:
Mailing Address - City:KECHI
Mailing Address - State:KS
Mailing Address - Zip Code:67067-8630
Mailing Address - Country:US
Mailing Address - Phone:316-841-7042
Mailing Address - Fax:
Practice Address - Street 1:452 CHEYENNE CT
Practice Address - Street 2:
Practice Address - City:KECHI
Practice Address - State:KS
Practice Address - Zip Code:67067-8630
Practice Address - Country:US
Practice Address - Phone:316-841-7042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS55469367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK900522611Medicare PIN