Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QS0010X | Family Doctor - Sports Medicine | 20A4724 | CA |
NPI | 1053497685 |
---|---|
Provider Name | Michael Henehan |
First Address | San Jose, CA 95128-1633 |
Second Address | San Jose, CA 95128-1633 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/10/2006 |
Last Update Date | 16/02/2012 |