Provider Demographics
NPI:1134678790
Name:HANSEN, MICHAEL (CST)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:HANSEN
Suffix:
Gender:M
Credentials:CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 VISA DR
Mailing Address - Street 2:STE 1
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761
Mailing Address - Country:US
Mailing Address - Phone:309-846-4716
Mailing Address - Fax:309-454-7348
Practice Address - Street 1:1604 VISA DR
Practice Address - Street 2:STE 1
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761
Practice Address - Country:US
Practice Address - Phone:309-846-4716
Practice Address - Fax:309-454-7348
Is Sole Proprietor?:No
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL238.000.498246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist