Basic Information
| Provider Information | |||||||||
| NPI: | 1184685737 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANSON | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | ALVIN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9000 | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810089000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195532200 | ||||||||
| FaxNumber: | 7195532216 | ||||||||
| Practice Location | |||||||||
| Address1: | 3676 PARKER BLVD | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810082212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195532200 | ||||||||
| FaxNumber: | 7195532216 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 02/04/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 17496 | CO | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 01174960 | 05 | CO | MEDICAID |