Healthcare Provider Details

I. General information

NPI: 1184615239
Provider Name (Legal Business Name): DAVID B HENDERSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 07/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1638 OWEN DR
FAYETTEVILLE NC
28304-3424
US

IV. Provider business mailing address

PO BOX 40908 ATTN: MANAGED CARE PLANNING
FAYETTEVILLE NC
28309-0908
US

V. Phone/Fax

Practice location:
  • Phone: 910-609-4000
  • Fax:
Mailing address:
  • Phone: 910-615-6949
  • Fax: 910-615-9761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number100436
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number100436
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: