Provider Demographics
NPI:1003874389
Name:HANSON, BEVERLY (PA)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:HANSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1758
Mailing Address - Country:US
Mailing Address - Phone:208-782-3993
Mailing Address - Fax:208-782-3994
Practice Address - Street 1:98 POPLAR ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1758
Practice Address - Country:US
Practice Address - Phone:208-782-3993
Practice Address - Fax:208-782-3994
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPAG-012363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010167603OtherRBS LAMERE
IDHPAC6OtherBLUE CROSS OLD
IDPAJ80OtherBCS LAMERE
ID000010154328OtherREGENCE BLUE SHIELD
IDHB405OtherBLUE CROSS
ID807338600Medicaid
ID1667444Medicare PIN
ID000010167603OtherRBS LAMERE
IDP00456536Medicare PIN
ID16674441Medicare PIN