Provider Demographics
NPI:1194186130
Name:HANSON, JEREMY RYAN (DO)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:RYAN
Last Name:HANSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 CLARKSON AVE BLDG E
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-2054
Mailing Address - Country:US
Mailing Address - Phone:718-245-3131
Mailing Address - Fax:718-245-3687
Practice Address - Street 1:451 CLARKSON AVE BLDG E
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2054
Practice Address - Country:US
Practice Address - Phone:718-245-3131
Practice Address - Fax:718-245-3687
Is Sole Proprietor?:No
Enumeration Date:2016-03-18
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY291797207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05994165Medicaid