Basic Information
Provider Information | |||||||||
NPI: | 1699941021 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HANSEN | ||||||||
FirstName: | BRUCE | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3570 | ||||||||
Address2: |   | ||||||||
City: | SALT LAKE CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 841103570 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8009459877 | ||||||||
FaxNumber: | 7707016675 | ||||||||
Practice Location | |||||||||
Address1: | 1055 N. CURTIS ROAD | ||||||||
Address2: |   | ||||||||
City: | BOISE | ||||||||
State: | ID | ||||||||
PostalCode: | 837061309 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2083672559 | ||||||||
FaxNumber: | 7707016675 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/06/2008 | ||||||||
LastUpdateDate: | 11/07/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 02003137A | IN | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207L00000X | 9528888-1204 | UT | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207L00000X | O-0636 | ID | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
No ID Information.