Basic Information
| Provider Information | |||||||||
| NPI: | 1790759454 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANSEN | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | ANTHONY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 LAWN AVE | ||||||||
| Address2: | BLDG 3 | ||||||||
| City: | SELLERSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 189601575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152573700 | ||||||||
| FaxNumber: | 2152570360 | ||||||||
| Practice Location | |||||||||
| Address1: | 711 LAWN AVE | ||||||||
| Address2: | BLDG 3 | ||||||||
| City: | SELLERSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 189601575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152573700 | ||||||||
| FaxNumber: | 2152570360 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | MD0009900E | PA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0683454 | 05 | PA | MEDICAID |