Basic Information
| Provider Information | |||||||||
| NPI: | 1467683243 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANSEN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | CARONITI | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARONITI | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | CATHERINE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 9 | ||||||||
| Address2: | |||||||||
| City: | LAUREL FORK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 243520009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2763982292 | ||||||||
| FaxNumber: | 2763983331 | ||||||||
| Practice Location | |||||||||
| Address1: | 14558 DANVILLE PIKE | ||||||||
| Address2: | |||||||||
| City: | LAUREL FORK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 243523982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2763982292 | ||||||||
| FaxNumber: | 2763983331 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2009 | ||||||||
| LastUpdateDate: | 07/21/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0102203001 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208D00000X | 0102203001 | VA | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.