Provider Demographics
NPI:1235105529
Name:HANSON, SANDRA LEE (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LEE
Last Name:HANSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 MAR WALT DR
Mailing Address - Street 2:
Mailing Address - City:FT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6706
Mailing Address - Country:US
Mailing Address - Phone:850-862-3127
Mailing Address - Fax:
Practice Address - Street 1:918 MAR WALT DR
Practice Address - Street 2:
Practice Address - City:FT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6706
Practice Address - Country:US
Practice Address - Phone:850-862-3127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME46727208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
46192Medicare PIN
FLD62484Medicare UPIN