Basic Information
| Provider Information | |||||||||
| NPI: | 1659433795 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENRIQUES | ||||||||
| FirstName: | JOHN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 515 W COURT ST | ||||||||
| Address2: | |||||||||
| City: | PASCO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993013737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095472204 | ||||||||
| FaxNumber: | 5095453960 | ||||||||
| Practice Location | |||||||||
| Address1: | 515 W COURT ST | ||||||||
| Address2: | |||||||||
| City: | PASCO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993013737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095472204 | ||||||||
| FaxNumber: | 5095453960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 01/15/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD00011817 | WA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1659433795 | 05 | WA | MEDICAID |