Provider Demographics
NPI:1164622098
Name:PRAIRIE DERMATOLOGY PC
Entity Type:Organization
Organization Name:PRAIRIE DERMATOLOGY PC
Other - Org Name:ABERDEEN DERMATOLOGY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DERMATOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TY
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:605-226-0560
Mailing Address - Street 1:3 LAFAYETTE ST S
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57401-5524
Mailing Address - Country:US
Mailing Address - Phone:605-226-0560
Mailing Address - Fax:605-226-1653
Practice Address - Street 1:3 LAFAYETTE ST S
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-5524
Practice Address - Country:US
Practice Address - Phone:605-226-0560
Practice Address - Fax:605-226-1653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD7021261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty