Provider Demographics
NPI:1881048205
Name:HENDERSHOT, BLAIR (DPM)
Entity type:Individual
Prefix:
First Name:BLAIR
Middle Name:
Last Name:HENDERSHOT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3777 PECOS MCLEOD
Mailing Address - Street 2:STE 103
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-4265
Mailing Address - Country:US
Mailing Address - Phone:702-434-2023
Mailing Address - Fax:
Practice Address - Street 1:3777 PECOS MCLEOD STE 103
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-4265
Practice Address - Country:US
Practice Address - Phone:702-324-2713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-21
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
211D00000X
NV2052213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No211D00000XPodiatric Medicine & Surgery Service ProvidersAssistant, Podiatric