Basic Information
| Provider Information | |||||||||
| NPI: | 1689956484 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANSEN | ||||||||
| FirstName: | HANS | ||||||||
| MiddleName: | JUSTIN | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 43 | ||||||||
| Address2: | |||||||||
| City: | KOTZEBUE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997520043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074423321 | ||||||||
| FaxNumber: | 9074427250 | ||||||||
| Practice Location | |||||||||
| Address1: | 436 5TH & TED STEVENS WAY | ||||||||
| Address2: | |||||||||
| City: | KOTZEBUE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997520043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074423321 | ||||||||
| FaxNumber: | 9074427250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2011 | ||||||||
| LastUpdateDate: | 09/16/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2320 | AK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | HS19IP | 05 | AK | MEDICAID | HS19OP | 05 | AK | MEDICAID |