Provider Demographics
NPI:1588751689
Name:HENRY, DEBORAH (PAC)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:HENRY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 PIERCE ST
Mailing Address - Street 2:STE 300
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51101-1058
Mailing Address - Country:US
Mailing Address - Phone:712-226-2600
Mailing Address - Fax:712-226-2605
Practice Address - Street 1:3250 PLAZA DR
Practice Address - Street 2:
Practice Address - City:SOUTH SIOUX CITY
Practice Address - State:NE
Practice Address - Zip Code:68776-3144
Practice Address - Country:US
Practice Address - Phone:402-412-4220
Practice Address - Fax:402-494-1365
Is Sole Proprietor?:No
Enumeration Date:2006-10-09
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002741363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI0524008Medicare PIN
Q72394Medicare UPIN