Healthcare Provider Details

I. General information

NPI: 1881653277
Provider Name (Legal Business Name): ESTEBAN A HENAO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: STEVE HENAO MD

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 08/11/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 ELM ST NE
ALBUQUERQUE NM
87102-2512
US

IV. Provider business mailing address

345 W STEAMBOAT DR STE 601
DAKOTA DUNES SD
57049-5287
US

V. Phone/Fax

Practice location:
  • Phone: 505-841-1000
  • Fax: 505-843-2592
Mailing address:
  • Phone: 605-217-5610
  • Fax: 605-217-5533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number33756
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberMD2006-0041
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number12696
License Number StateSD
# 4
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMD2006-0041
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: