Healthcare Provider Details

I. General information

NPI: 1033442298
Provider Name (Legal Business Name): GARY LEE HENRIKSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2009
Last Update Date: 09/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

362 GREYWOLF RD
SEQUIM WA
98382-7574
US

IV. Provider business mailing address

362 GREYWOLF RD
SEQUIM WA
98382-7574
US

V. Phone/Fax

Practice location:
  • Phone: 360-683-7784
  • Fax:
Mailing address:
  • Phone: 360-683-7784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License NumberMD00014466
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberMD00014466
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: