Basic Information
| Provider Information | |||||||||
| NPI: | 1295881993 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANSON | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | NPP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 490 RIDGE RD E | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146211229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859222500 | ||||||||
| FaxNumber: | 5859222664 | ||||||||
| Practice Location | |||||||||
| Address1: | 490 RIDGE RD E | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146211229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859222500 | ||||||||
| FaxNumber: | 5859222664 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2007 | ||||||||
| LastUpdateDate: | 03/07/2012 | ||||||||
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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 | 363LP0808X | 400775 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 000560933001 | 01 | BC BS WESTERN NY | OTHER | P019400775 | 01 | EXCELLUS | OTHER | P019400775 | 01 | NY | EXCELLUS | OTHER | 117625EU | 01 | PREFERRED CARE | OTHER | 02777228 | 05 | NY | MEDICAID |