Basic Information
| Provider Information | |||||||||
| NPI: | 1649217746 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | BRENT | ||||||||
| MiddleName: | |||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1751 N ASPEN AVE | ||||||||
| Address2: | |||||||||
| City: | BROKEN ARROW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740121197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187946008 | ||||||||
| FaxNumber: | 9185163447 | ||||||||
| Practice Location | |||||||||
| Address1: | 8801 S 101ST EAST AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741335716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182944915 | ||||||||
| FaxNumber: | 9182944947 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 04/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 04/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 3954 | OK | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 3954 | OK | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200059770A | 05 | OK | MEDICAID | 900522349 | 01 | OK | MEDICARE GROUP PIN | OTHER |