Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2080A0000X | Adolescent Medicine | 100436 | NC |
NPI | 1184615239 |
---|---|
Provider Name | Mr. David B Henderson |
First Address | Fayetteville, NC 28309-0908 |
Second Address | Fayetteville, NC 28304-3424 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/10/2005 |
Last Update Date | 12/07/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
10436 | NORTH CAROLINA LICENSE (01) | NC |
1184615239 | (05) | SC |
1184615239 | TRICARE (01) |