Basic Information
Provider Information | |||||||||
NPI: | 1861433443 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HANSEN | ||||||||
FirstName: | THOMAS | ||||||||
MiddleName: | R | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HANSEN | ||||||||
OtherFirstName: | T | ||||||||
OtherMiddleName: | RANDY | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 5880 S HOSPITAL DR | ||||||||
Address2: |   | ||||||||
City: | GLOBE | ||||||||
State: | AZ | ||||||||
PostalCode: | 855019447 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9284253246 | ||||||||
FaxNumber: | 9284253859 | ||||||||
Practice Location | |||||||||
Address1: | 5880 S HOSPITAL DR | ||||||||
Address2: |   | ||||||||
City: | GLOBE | ||||||||
State: | AZ | ||||||||
PostalCode: | 855019447 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9284253246 | ||||||||
FaxNumber: | 9284253859 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2006 | ||||||||
LastUpdateDate: | 02/19/2015 | ||||||||
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 | 208600000X | 1803601205 | UT | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 208600000X | 18493 | AZ | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | Z172537 | 01 | AZ | MCPTAN | OTHER |