Basic Information
| Provider Information | |||||||||
| NPI: | 1174740781 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUHADWAY | ||||||||
| FirstName: | HENRY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | RN, MSN, ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1007 SUGAR CREEK CT | ||||||||
| Address2: | |||||||||
| City: | SAINT PETERS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633767425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149108460 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5000 MANCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631102012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147475800 | ||||||||
| FaxNumber: | 3147475866 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 75908 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 427544606 | 05 | MO | MEDICAID |