Provider Demographics
NPI:1346221793
Name:HANSON, MARY LOU (BS, RN, CNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOU
Last Name:HANSON
Suffix:
Gender:F
Credentials:BS, RN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 6TH AVENUE NORTH
Mailing Address - Street 2:ST. CLOUD HOSPITAL
Mailing Address - City:ST. CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1901
Mailing Address - Country:US
Mailing Address - Phone:320-251-2700
Mailing Address - Fax:320-229-5109
Practice Address - Street 1:1406 6TH AVENUE NORTH
Practice Address - Street 2:ST. CLOUD HOSPITAL
Practice Address - City:ST. CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1901
Practice Address - Country:US
Practice Address - Phone:320-251-2700
Practice Address - Fax:320-229-5109
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR0741327363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
0407455OtherMEDICA HEALTH PLANS
110429OtherUCARE
1006658OtherPREFERRED ONE
HP25437OtherHEALTH PARTNERS
50A57HAOtherBLUE CROSS BLUE SHIELD
912742900OtherMEDICAL ASSISTANCE
50A57HAOtherBLUE CROSS BLUE SHIELD
R04808Medicare UPIN
HP25437OtherHEALTH PARTNERS
C11369Medicare ID - Type UnspecifiedRR MEDICARE