Provider Demographics
NPI:1386674430
Name:HANSEEN, ROSS BYRON (MD)
Entity Type:Individual
Prefix:
First Name:ROSS
Middle Name:BYRON
Last Name:HANSEEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ROSS
Other - Middle Name:B
Other - Last Name:HANSEEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:385-282-2000
Mailing Address - Fax:385-282-2001
Practice Address - Street 1:389 S 900 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2310
Practice Address - Country:US
Practice Address - Phone:385-282-2000
Practice Address - Fax:385-282-2001
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT178571-1205207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005545617Medicare PIN
D20391Medicare UPIN