Basic Information
| Provider Information | |||||||||
| NPI: | 1194186130 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANSON | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | RYAN | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 451 CLARKSON AVE BLDG E | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112032054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182453131 | ||||||||
| FaxNumber: | 7182453687 | ||||||||
| Practice Location | |||||||||
| Address1: | 451 CLARKSON AVE BLDG E | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112032054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182453131 | ||||||||
| FaxNumber: | 7182453687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2016 | ||||||||
| LastUpdateDate: | 11/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 291797 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 05994165 | 05 | NY | MEDICAID |