Provider Demographics
NPI:1073132718
Name:HANSEN, AMANDA (PA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:HANSEN
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 1:6300 E LAKE BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:VANCLEAVE
Mailing Address - State:MS
Mailing Address - Zip Code:39565-6771
Mailing Address - Country:US
Mailing Address - Phone:228-230-2663
Mailing Address - Fax:
Practice Address - Street 1:6300 E LAKE BLVD STE 201
Practice Address - Street 2:
Practice Address - City:VANCLEAVE
Practice Address - State:MS
Practice Address - Zip Code:39565-6771
Practice Address - Country:US
Practice Address - Phone:228-230-2663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-13
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00709363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8QC851OtherBCBS - UNIVERSAL SURGICAL ASSISTANTS
TX8QA716OtherBCBS - BLUE STAR SURGICAL
TX8PX958OtherBCBS - US MSO
TX8QC670OtherBCBS - XCITE SURGICAL
TX8QF482OtherBCBS - UNIVERSAL SURGICAL PARTNERS
TXPA14161OtherTEXAS MEDICAL BOARD