Healthcare Provider Details

I. General information

NPI: 1801195375
Provider Name (Legal Business Name): WESLEY SCOTT HENRICKSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2011
Last Update Date: 03/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 11TH AVE
LONGVIEW WA
98632-2503
US

IV. Provider business mailing address

971 11TH AVE
LONGVIEW WA
98632-2503
US

V. Phone/Fax

Practice location:
  • Phone: 360-577-1771
  • Fax: 360-423-1405
Mailing address:
  • Phone: 360-577-1771
  • Fax: 360-423-1405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD60477315
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: