Provider Demographics
NPI:1164558151
Name:HANSEN, TRAVIS D (MD)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:D
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 1:1230 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-5066
Mailing Address - Country:US
Mailing Address - Phone:507-625-1811
Mailing Address - Fax:
Practice Address - Street 1:1400 MADISON AVE
Practice Address - Street 2:SUITE352
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-5473
Practice Address - Country:US
Practice Address - Phone:507-625-1811
Practice Address - Fax:507-625-3928
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD#56962084P0800X
MN569022084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDI37321Medicare UPIN
SDI00427Medicare PIN
MN260003856Medicare PIN