Provider Demographics
NPI:1780498139
Name:HENDERSON, BLAIR
Entity type:Individual
Prefix:
First Name:BLAIR
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 1:3D MARINE DIVISION OPC 563
Mailing Address - Street 2:BOX 281
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96388-9001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3D MARINE DIVISION OPC 563
Practice Address - Street 2:BOX 281
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96388-9001
Practice Address - Country:US
Practice Address - Phone:315-265-7035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-05
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman