Basic Information
| Provider Information | |||||||||
| NPI: | 1144292129 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | ANITA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15645 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891145645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022427308 | ||||||||
| FaxNumber: | 7022408790 | ||||||||
| Practice Location | |||||||||
| Address1: | 7061 GRAND MONTECITO PKWY | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891490287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027503900 | ||||||||
| FaxNumber: | 7027503916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2006 | ||||||||
| LastUpdateDate: | 02/20/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 10115 | NV | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 3102646 | 05 | NV | MEDICAID | P00054853 | 01 | NV | RAILROAD MEDICARE | OTHER | 2018546 | 05 | NV | MEDICAID |