Provider Demographics
NPI:1245331420
Name:HENDERSON, MICHAEL (NP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 842373
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-2373
Mailing Address - Country:US
Mailing Address - Phone:866-916-5259
Mailing Address - Fax:231-922-4030
Practice Address - Street 1:11800 ASTORIA BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77089-6041
Practice Address - Country:US
Practice Address - Phone:281-420-8600
Practice Address - Fax:281-837-8282
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX610424363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8D0743Medicare PIN
TX8D1649Medicare PIN
TX8C8080Medicare PIN
S82307Medicare UPIN
TX8C7533Medicare PIN