Provider Demographics
NPI:1962768879
Name:HENDERSON, HUNTER B (CRNA)
Entity type:Individual
Prefix:MR
First Name:HUNTER
Middle Name:B
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 1:1900 EXETER RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-2954
Mailing Address - Country:US
Mailing Address - Phone:601-529-9903
Mailing Address - Fax:
Practice Address - Street 1:1900 EXETER RD
Practice Address - Street 2:SUITE 210
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-2954
Practice Address - Country:US
Practice Address - Phone:901-818-2183
Practice Address - Fax:901-682-9522
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-04
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR871673163W00000X
TN16751367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR194804001Medicaid
P01117345OtherRAILROAD MEDICARE
TN1530030Medicaid
MS04534393Medicaid
1962768879OtherCHAMPUS/TRICARE
TN4333549OtherBCBST
TN1530030Medicaid