Provider Demographics
NPI:1255318739
Name:HANSEN, LYNN A (DC)
Entity Type:Individual
Prefix:DR
First Name:LYNN
Middle Name:A
Last Name:HANSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 OAKLEY AVE
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-1840
Mailing Address - Country:US
Mailing Address - Phone:208-878-2273
Mailing Address - Fax:208-878-2275
Practice Address - Street 1:1210 OAKLEY AVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-1840
Practice Address - Country:US
Practice Address - Phone:208-878-2273
Practice Address - Fax:208-878-2275
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-27
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA936111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC1450OtherBLUE CROSS
ID000010027304OtherPEGENCE BLUE S
ID1674191Medicare ID - Type Unspecified
U79040Medicare UPIN