Provider Demographics
NPI:1164491460
Name:HANSEN, STEPHEN M (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:M
Last Name:HANSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 HOSPITAL WAY STE A
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2762
Mailing Address - Country:US
Mailing Address - Phone:208-478-4522
Mailing Address - Fax:208-712-6868
Practice Address - Street 1:950 HOSPITAL WAY STE A
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2762
Practice Address - Country:US
Practice Address - Phone:208-478-4522
Practice Address - Fax:208-712-6868
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7102972-1205207XS0117X
IDM-11666207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8425670Medicaid
I17974Medicare UPIN
WA8425670Medicaid