Healthcare Provider Details

I. General information

NPI: 1508199365
Provider Name (Legal Business Name): JUSTIN ERIC HENDERSON APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2009
Last Update Date: 07/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 KAPAHULU AVE PH
HONOLULU HI
96815-3853
US

IV. Provider business mailing address

2916 DATE ST 20C
HONOLULU HI
96816-1184
US

V. Phone/Fax

Practice location:
  • Phone: 808-561-5424
  • Fax:
Mailing address:
  • Phone: 808-561-5424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number1338
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: