Provider Demographics
NPI:1366038465
Name:ESTEBAN, ERNEST CONSTANTINE
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:CONSTANTINE
Last Name:ESTEBAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 W BASELINE RD STE 105-264
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-1100
Mailing Address - Country:US
Mailing Address - Phone:623-203-9737
Mailing Address - Fax:480-945-5339
Practice Address - Street 1:5235 S KYRENE RD STE 105-264
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-1779
Practice Address - Country:US
Practice Address - Phone:480-466-7473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ000134171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ000134OtherACUPUNCTURE LICENSE