Healthcare Provider Details

I. General information

NPI: 1881048205
Provider Name (Legal Business Name): BLAIR HENDERSHOT DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2016
Last Update Date: 06/17/2020
Certification Date: 06/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3777 PECOS MCLEOD STE 103
LAS VEGAS NV
89121-4265
US

IV. Provider business mailing address

3777 PECOS MCLEOD STE 103
LAS VEGAS NV
89121-4265
US

V. Phone/Fax

Practice location:
  • Phone: 702-324-2713
  • Fax:
Mailing address:
  • Phone: 702-434-2023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code211D00000X
TaxonomyPodiatric Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number2052
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: