Provider Demographics
NPI:1992768618
Name:HENNE, MANFRED (MD)
Entity type:Individual
Prefix:DR
First Name:MANFRED
Middle Name:
Last Name:HENNE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1399
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-9099
Mailing Address - Country:US
Mailing Address - Phone:360-598-3141
Mailing Address - Fax:
Practice Address - Street 1:20700 BOND RD NE
Practice Address - Street 2:BLDG B
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-9099
Practice Address - Country:US
Practice Address - Phone:360-598-3141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000252312085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB28654Medicare ID - Type Unspecified