Provider Demographics
NPI:1396007316
Name:HANSEN, KELLEN TAGE (DO)
Entity Type:Individual
Prefix:
First Name:KELLEN
Middle Name:TAGE
Last Name:HANSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 N CENTER ST STE 100
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-7498
Mailing Address - Country:US
Mailing Address - Phone:801-753-7770
Mailing Address - Fax:801-753-7775
Practice Address - Street 1:3401 N CENTER ST STE 100
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043
Practice Address - Country:US
Practice Address - Phone:801-753-7770
Practice Address - Fax:801-753-7775
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02004307A207P00000X, 207Q00000X
UT10266619-1204207Q00000X, 207QS0010X
IN390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN192590006Medicare PIN
IN256480018Medicare PIN
IN264430225Medicare PIN
IN201093150Medicaid