Provider Demographics
NPI:1235148164
Name:HANSON, MICHELLE NYBERG (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:NYBERG
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 1:3701 12TH ST N STE 201
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2253
Mailing Address - Country:US
Mailing Address - Phone:320-253-6554
Mailing Address - Fax:320-253-1218
Practice Address - Street 1:111 17TH AVE E
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-5273
Practice Address - Country:US
Practice Address - Phone:320-762-1511
Practice Address - Fax:320-762-6101
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN37636207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNG24380Medicare UPIN