Basic Information
| Provider Information | |||||||||
| NPI: | 1689217911 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | JEFFREY | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1387 | ||||||||
| Address2: | |||||||||
| City: | HAYDEN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838351387 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084150299 | ||||||||
| FaxNumber: | 2086252070 | ||||||||
| Practice Location | |||||||||
| Address1: | 740 MCKINLEY AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | KELLOGG | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838372693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087831267 | ||||||||
| FaxNumber: | 8448073782 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2019 | ||||||||
| LastUpdateDate: | 08/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA1806 | ID | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | PA1806 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | PA1806 | 01 | ID | LICENSE | OTHER |