Basic Information
| Provider Information | |||||||||
| NPI: | 1710923560 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANSEN | ||||||||
| FirstName: | SONJA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 819 BLOOMINGTON RD | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618202101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173561558 | ||||||||
| FaxNumber: | 2173568529 | ||||||||
| Practice Location | |||||||||
| Address1: | 819 BLOOMINGTON RD | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618202101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173561558 | ||||||||
| FaxNumber: | 2173568529 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 03/02/2009 | ||||||||
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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 | 207Q00000X | 036118017 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | BH5552698 | 01 | FED DEA | OTHER |