Provider Demographics
NPI:1386179315
Name:HANSON, CALEB FRAZIER (ATC)
Entity Type:Individual
Prefix:
First Name:CALEB
Middle Name:FRAZIER
Last Name:HANSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 130
Mailing Address - Street 2:40W610 RT 64
Mailing Address - City:WASCO
Mailing Address - State:IL
Mailing Address - Zip Code:60183
Mailing Address - Country:US
Mailing Address - Phone:630-803-3936
Mailing Address - Fax:
Practice Address - Street 1:701 PRINCETON AVE SW
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35211-1303
Practice Address - Country:US
Practice Address - Phone:205-783-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-27
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL19772255A2300X
363AM0700X
AL1926363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer