Healthcare Provider Details

I. General information

NPI: 1467525949
Provider Name (Legal Business Name): DAN J HENDRICKSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 11/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 E HAWAII
NAMPA ID
83686
US

IV. Provider business mailing address

3340 E GOLDSTONE WAY
MERIDIAN ID
83642-1026
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-2100
  • Fax: 208-302-2125
Mailing address:
  • Phone: 208-302-2100
  • Fax: 208-302-2125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberM-9672
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberM-9672
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: