Basic Information
| Provider Information | |||||||||
| NPI: | 1568911832 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANSON | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 STATE ST STE 104 | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165071463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249330300 | ||||||||
| FaxNumber: | 7249330456 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 STATE ST | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165071450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148775295 | ||||||||
| FaxNumber: | 8148775299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2016 | ||||||||
| LastUpdateDate: | 10/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | OA003917 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | MA058564 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0110458261 | 05 | PA | MEDICAID |