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General NPI Number Information
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NPI Number | 1538639497
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Entity Type | Individual
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Provider Name | GOVERNOR HENRY HENDERSON III DNP
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Gender | Male
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Dates
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Enumeration Date | 12/04/2018
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Last Update Date | 04/01/2023
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Provider Practice Location Address
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Address Line | 75 COLONIA DE SALUD # 200
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City | SIERRA VISTA
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State | AZ
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Zip | 85635-2487
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Country | US
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Telephone | 520-263-2690
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Fax |
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Provider Business Mailing Address
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Address Line | 75 COLONIA DE SALUD # 200
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City | SIERRA VISTA
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State | AZ
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Zip | 85635-2487
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Country | US
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Telephone | 520-263-2690
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | RN252065
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 288860
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License Number State | AZ
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Taxonomy #3
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | RN252065
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License Number State | GA
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