Basic Information
| Provider Information | |||||||||
| NPI: | 1376581546 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANSEN | ||||||||
| FirstName: | DWAYNE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 185 | ||||||||
| Address2: | |||||||||
| City: | REXBURG | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834400185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086568442 | ||||||||
| FaxNumber: | 2086568453 | ||||||||
| Practice Location | |||||||||
| Address1: | 381 EAST 4TH NORTH | ||||||||
| Address2: | STE 100 | ||||||||
| City: | REXBURG | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086568442 | ||||||||
| FaxNumber: | 2086568453 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | M8427 | ID | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 48488 | 01 | ID | BLUE CROSS OF IDAHO | OTHER | BH5461950 | 01 | ID | DEA | OTHER | CS9440 | 01 | ID | IDAHO STATE BOARD OF PHAR | OTHER | M8427 | 01 | ID | IDAHO STATE LICENSE | OTHER |