Provider Demographics
NPI:1528068335
Name:HENDERSON, GREGORY D (CRNA)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:D
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 CHERRY DR
Mailing Address - Street 2:
Mailing Address - City:SURFSIDE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29575-4111
Mailing Address - Country:US
Mailing Address - Phone:843-232-8078
Mailing Address - Fax:843-232-0328
Practice Address - Street 1:300 SINGLETON RIDGE RD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-9142
Practice Address - Country:US
Practice Address - Phone:843-347-8037
Practice Address - Fax:843-520-8403
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN477367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00123825OtherRAILROAD MEDICARE
SCAN0753Medicaid
Q32955Medicare UPIN