Healthcare Provider Details

I. General information

NPI: 1215293600
Provider Name (Legal Business Name): ANDREW DEAN HENSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 11/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3754 HIGHWAY 90 STE 200
PACE FL
32571-1098
US

IV. Provider business mailing address

PO BOX 2699
PENSACOLA FL
32513-2699
US

V. Phone/Fax

Practice location:
  • Phone: 850-416-5200
  • Fax: 850-416-5201
Mailing address:
  • Phone: 850-416-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS13224
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: