Basic Information
| Provider Information | |||||||||
| NPI: | 1144848342 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANSEN | ||||||||
| FirstName: | CONNOR | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E 75TH ST STE 500 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176217547 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8890 E 116TH ST STE 130 | ||||||||
| Address2: | |||||||||
| City: | FISHERS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460382856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176216740 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2020 | ||||||||
| LastUpdateDate: | 03/22/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 05013747A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 05013747A | 01 | IN | STATE LICENSE | OTHER |