Basic Information
| Provider Information | |||||||||
| NPI: | 1659792570 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANSON | ||||||||
| FirstName: | MOLLY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 833 CHESTNUT ST | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074414 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 833 CHESTNUT ST | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159557190 | ||||||||
| FaxNumber: | 2159239186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2013 | ||||||||
| LastUpdateDate: | 08/26/2014 | ||||||||
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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 | 363LA2200X | SP013501 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LG0600X | SP013501 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 102925851 | 05 | PA | MEDICAID |