Provider Demographics
NPI:1023076643
Name:HENRY, JOHN N JR (PAC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:N
Last Name:HENRY
Suffix:JR
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756-1000
Mailing Address - Country:US
Mailing Address - Phone:603-650-5704
Mailing Address - Fax:
Practice Address - Street 1:189 PROUTY DR
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:VT
Practice Address - Zip Code:05855-9820
Practice Address - Country:US
Practice Address - Phone:802-334-7331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAAP1946363A00000X
NY027167363A00000X
NH1089363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q60201Medicare UPIN
AP2566Medicare ID - Type Unspecified