Provider Demographics
NPI:1447275961
Name:HENDERSON, WELDON S (CRNA)
Entity type:Individual
Prefix:
First Name:WELDON
Middle Name:S
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 1:419 W GRAY ST
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-7117
Mailing Address - Country:US
Mailing Address - Phone:405-809-4200
Mailing Address - Fax:405-364-5379
Practice Address - Street 1:4750 N EXPRESSWAY
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78526-4120
Practice Address - Country:US
Practice Address - Phone:956-554-2014
Practice Address - Fax:956-554-2001
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0025031367500000X
TX535862367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100781230AMedicaid
TX89953UOtherBCBS
OK100781230AMedicaid
TX8F9855Medicare PIN