Provider Demographics
NPI:1871038109
Name:HENDERSON, DEREK
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3726 BROADWAY STE 201
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-3788
Mailing Address - Country:US
Mailing Address - Phone:425-317-9119
Mailing Address - Fax:
Practice Address - Street 1:3726 BROADWAY STE 201
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-3788
Practice Address - Country:US
Practice Address - Phone:425-317-9119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-22
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1680363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant