Basic Information
Provider Information | |||||||||
NPI: | 1275920506 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HANSEN | ||||||||
FirstName: | LAURA | ||||||||
MiddleName: | WORTH | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WORTH | ||||||||
OtherFirstName: | LAURA | ||||||||
OtherMiddleName: | ELIZABETH | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | D.O. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1311 SHADY LN | ||||||||
Address2: |   | ||||||||
City: | HONDO | ||||||||
State: | TX | ||||||||
PostalCode: | 788611012 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3200 AVENUE E | ||||||||
Address2: |   | ||||||||
City: | HONDO | ||||||||
State: | TX | ||||||||
PostalCode: | 788613525 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8304267444 | ||||||||
FaxNumber: | 8304267468 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/24/2015 | ||||||||
LastUpdateDate: | 08/23/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/23/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | R0244 | TX | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.