Basic Information
| Provider Information | |||||||||
| NPI: | 1023074655 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANSON | ||||||||
| FirstName: | GRETCHEN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | CNNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2910 CENTRE POINTE DRIVE | ||||||||
| Address2: | 35-121A CHILDRENS HEALTH CARE | ||||||||
| City: | ROSEVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6518552327 | ||||||||
| FaxNumber: | 6518552310 | ||||||||
| Practice Location | |||||||||
| Address1: | 1575 BEAM AVE | ||||||||
| Address2: | |||||||||
| City: | MAPLEWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551091126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512327000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2006 | ||||||||
| LastUpdateDate: | 07/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LN0005X | R1402513 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal, Critical Care | 363LN0000X | R1402513 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal |
ID Information
| ID | Type | State | Issuer | Description | 305435700 | 05 | MN | MEDICAID |