Provider Demographics
NPI:1134117153
Name:HANSON, RICHARD ENNISS JR (PA, MPAS)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:ENNISS
Last Name:HANSON
Suffix:JR
Gender:M
Credentials:PA, MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19416 CADE CT
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-4163
Mailing Address - Country:US
Mailing Address - Phone:405-640-9005
Mailing Address - Fax:
Practice Address - Street 1:19416 CADE CT
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73012-4163
Practice Address - Country:US
Practice Address - Phone:405-640-9005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200266340AMedicaid
OK200266340AMedicaid