Provider Demographics
NPI:1114069358
Name:HANSON, MARIJO (PA)
Entity Type:Individual
Prefix:
First Name:MARIJO
Middle Name:
Last Name:HANSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MARIJO
Other - Middle Name:
Other - Last Name:DEDEKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3082 MCMURRAY DR
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:CA
Mailing Address - Zip Code:96007-3544
Mailing Address - Country:US
Mailing Address - Phone:530-365-4420
Mailing Address - Fax:530-365-5186
Practice Address - Street 1:3082 MCMURRAY DR
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:CA
Practice Address - Zip Code:96007-3544
Practice Address - Country:US
Practice Address - Phone:305-365-4420
Practice Address - Fax:530-365-5186
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16359363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ20041ZOtherSITE PTAN
CAZZZ20041ZOtherSITE PTAN