Provider Demographics
NPI:1316383953
Name:HENDERSON, SHASTA ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:SHASTA
Middle Name:ELIZABETH
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 RED BUCKEYE CT
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-8600
Mailing Address - Country:US
Mailing Address - Phone:310-721-8870
Mailing Address - Fax:
Practice Address - Street 1:5601 W EUGIE AVE STE 100
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-1256
Practice Address - Country:US
Practice Address - Phone:602-865-4510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-21
Last Update Date:2025-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC83022207XX0801X
AZ74368207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic TraumaGroup - Single Specialty