Basic Information
| Provider Information | |||||||||
| NPI: | 1114069358 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANSON | ||||||||
| FirstName: | MARIJO | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DEDEKER | ||||||||
| OtherFirstName: | MARIJO | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3082 MCMURRAY DR | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960073544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5303654420 | ||||||||
| FaxNumber: | 5303655186 | ||||||||
| Practice Location | |||||||||
| Address1: | 3082 MCMURRAY DR | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960073544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3053654420 | ||||||||
| FaxNumber: | 5303655186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2007 | ||||||||
| LastUpdateDate: | 10/25/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA16359 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.