Provider Demographics
NPI:1073515631
Name:HANSEN, GARY PAUL (MD)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:PAUL
Last Name:HANSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 PHYSICIANS DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4620
Mailing Address - Country:US
Mailing Address - Phone:850-878-1171
Mailing Address - Fax:850-942-1291
Practice Address - Street 1:1609 PHYSICIANS DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4620
Practice Address - Country:US
Practice Address - Phone:850-878-1171
Practice Address - Fax:850-942-1291
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME32434207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL036688900Medicaid
FL87244ZMedicare ID - Type Unspecified
D54595Medicare UPIN