Healthcare Provider Details

I. General information

NPI: 1033352190
Provider Name (Legal Business Name): ESTEBAN HENNINGS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2009
Last Update Date: 08/01/2021
Certification Date: 08/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 S MARYLAND PKWY STE 512
LAS VEGAS NV
89109-2427
US

IV. Provider business mailing address

284-C E LAKE MEAD PKWY PMB 261
HENDERSON NV
89015-6433
US

V. Phone/Fax

Practice location:
  • Phone: 702-685-7700
  • Fax: 702-629-7800
Mailing address:
  • Phone: 702-685-7700
  • Fax: 702-629-7800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: ESTEBAN C HENNINGS
Title or Position: PRESIDENT
Credential: MD
Phone: 702-685-7700