Basic Information
| Provider Information | |||||||||
| NPI: | 1699242156 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANSELMAN | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | GARET | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2129 | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797602129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4326403462 | ||||||||
| FaxNumber: | 4326402897 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4326403462 | ||||||||
| FaxNumber: | 4326402897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2018 | ||||||||
| LastUpdateDate: | 11/07/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA13184 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.