Provider Demographics
NPI:1164403275
Name:CHU HANSON, ELIZABETH M (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:M
Last Name:CHU HANSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 WARREN STREET, 3RD FL
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPT
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135
Mailing Address - Country:US
Mailing Address - Phone:617-562-5359
Mailing Address - Fax:617-562-5415
Practice Address - Street 1:830 OAK STREET
Practice Address - Street 2:SUITE 123E
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301
Practice Address - Country:US
Practice Address - Phone:617-526-5359
Practice Address - Fax:617-562-5415
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA133138363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0366650Medicaid
MANP1875Medicare ID - Type Unspecified
MAF05769Medicare UPIN