Provider Demographics
NPI:1114966751
Name:HANSON, SUSAN JANELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:JANELLE
Last Name:HANSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4450 31ST AVE S
Mailing Address - Street 2:STE 102
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-4557
Mailing Address - Country:US
Mailing Address - Phone:701-280-2033
Mailing Address - Fax:701-232-5578
Practice Address - Street 1:1707 GOLD DR
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6413
Practice Address - Country:US
Practice Address - Phone:701-280-2033
Practice Address - Fax:701-232-5578
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0312363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND11277Medicaid
2303752OtherAMERICAS PPO
ND24823OtherND BLUE SHIELD
NDQ25266OtherND WORKERS COMP
P50714OtherHEALTH PARTNERS
01-19213OtherMEDICA
HN10910428OtherPREFERRED ONE
2303752OtherAMERICAS PPO
P50714OtherHEALTH PARTNERS
ND24823Medicare ID - Type Unspecified