Provider Demographics
NPI:1366500449
Name:HANSEN, ERIC C (MD)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:C
Last Name:HANSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:150 ARROWHEAD DRIVE
Mailing Address - Street 2:STE 2
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930
Mailing Address - Country:US
Mailing Address - Phone:307-789-8881
Mailing Address - Fax:307-789-6470
Practice Address - Street 1:150 ARROWHEAD DRIVE
Practice Address - Street 2:STE 2
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930
Practice Address - Country:US
Practice Address - Phone:307-789-8881
Practice Address - Fax:307-789-6470
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WY6429A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY119741000Medicaid
WYW310473Medicare ID - Type Unspecified
WY119741000Medicaid