Provider Demographics
NPI:1508183989
Name:HANSEN, TERRY LEONID (MD)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:LEONID
Last Name:HANSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:LEONID
Other - Middle Name:TERRY
Other - Last Name:HANSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1540 JUAN TABO BLVD NE
Mailing Address - Street 2:STE A
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-4460
Mailing Address - Country:US
Mailing Address - Phone:505-800-7246
Mailing Address - Fax:505-207-5221
Practice Address - Street 1:201 CEDAR ST SE STE 6600
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106
Practice Address - Country:US
Practice Address - Phone:505-724-4300
Practice Address - Fax:505-724-4384
Is Sole Proprietor?:No
Enumeration Date:2010-04-26
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NMMD2015-0101208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM85936529Medicaid