Provider Demographics
NPI:1396841987
Name:HANSON, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:HANSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2949
Mailing Address - Street 2:
Mailing Address - City:CHELAN
Mailing Address - State:WA
Mailing Address - Zip Code:98816-2949
Mailing Address - Country:US
Mailing Address - Phone:509-293-6809
Mailing Address - Fax:509-888-2231
Practice Address - Street 1:414 E WOODIN AVE
Practice Address - Street 2:
Practice Address - City:CHELAN
Practice Address - State:WA
Practice Address - Zip Code:98816-9648
Practice Address - Country:US
Practice Address - Phone:509-293-6809
Practice Address - Fax:509-888-2231
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00013982207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8290900Medicaid
WA8290900Medicaid
WAAB20786Medicare ID - Type Unspecified