Basic Information
Provider Information | |||||||||
NPI: | 1376545954 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HENNER | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | RICHARD | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9229 LBJ FWY | ||||||||
Address2: | STE 250 | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752433405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8003460747 | ||||||||
FaxNumber: | 9727392638 | ||||||||
Practice Location | |||||||||
Address1: | 3100 N TENAYA WAY | ||||||||
Address2: |   | ||||||||
City: | LAS VEGAS | ||||||||
State: | NV | ||||||||
PostalCode: | 891280436 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9729153600 | ||||||||
FaxNumber: | 9729153636 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/12/2005 | ||||||||
LastUpdateDate: | 07/28/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 1040 | NV | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207PE0004X | 1040 | NV | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
ID | Type | State | Issuer | Description | 002180367 | 05 | NV |   | MEDICAID |