Provider Demographics
NPI:1902071632
Name:HENDERSON, PAUL WALTER
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:WALTER
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 COUNTY ROAD 1250
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-7414
Mailing Address - Country:US
Mailing Address - Phone:662-720-6370
Mailing Address - Fax:
Practice Address - Street 1:100 HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-3354
Practice Address - Country:US
Practice Address - Phone:662-720-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSRCP2642227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered