Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207L00000X | Anesthesiologist | 16232 | NE |
N | 207L00000X | Anesthesiologist | 24054 | IA |
NPI | 1013025535 |
---|---|
Provider Name | Marvin Graves Henderson |
First Address | Omaha, NE 68134 |
Second Address | Omaha, NE 68122 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/08/2006 |
Last Update Date | 19/02/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2213876 | (05) | IA |
47-0550438-13 | (05) | NE |
A02388 | (02) |