Basic Information
| Provider Information | |||||||||
| NPI: | 1184615239 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40908 | ||||||||
| Address2: | ATTN: MANAGED CARE PLANNING | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283090908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106156949 | ||||||||
| FaxNumber: | 9106159761 | ||||||||
| Practice Location | |||||||||
| Address1: | 1638 OWEN DR | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283043424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106094000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 07/12/2016 | ||||||||
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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 | 2080A0000X | 100436 | NC | N | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 363A00000X | 100436 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1184615239 | 01 | TRICARE | OTHER | 1184615239 | 05 | SC | MEDICAID | 10436 | 01 | NC | NORTH CAROLINA LICENSE | OTHER |