Provider Demographics
NPI:1215372198
Name:HANSEN, MATTHEW DAVID (DPT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DAVID
Last Name:HANSEN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5650 S GREEN ST
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-5796
Mailing Address - Country:US
Mailing Address - Phone:801-743-1402
Mailing Address - Fax:
Practice Address - Street 1:5650 S GREEN ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84123-5796
Practice Address - Country:US
Practice Address - Phone:801-743-1402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-06
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT366390-2401225100000X
NM4273225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist