Provider Demographics
NPI:1124207170
Name:LEON W. HANSEN, MD PC
Entity Type:Organization
Organization Name:LEON W. HANSEN, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:LEON
Authorized Official - Middle Name:W
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-571-7777
Mailing Address - Street 1:9600 S 1300 E
Mailing Address - Street 2:300
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-3766
Mailing Address - Country:US
Mailing Address - Phone:801-571-7777
Mailing Address - Fax:801-523-1848
Practice Address - Street 1:9600 S 1300 E
Practice Address - Street 2:300
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-3766
Practice Address - Country:US
Practice Address - Phone:801-571-7777
Practice Address - Fax:801-523-1848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-26
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT171574-1205261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528709718013Medicaid